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The Baltimore Teachers Union                                        

 5800 Metro Drive, 2^nd Floor                                             

Baltimore, MD  21215                                                    

Baltimore City Public School System

200 E. North Avenue

Baltimore

Today’s Date:________________________

Sick Bank Committee

Baltimore Teachers Union

5800 Metro Drive

2nd Floor

Baltimore, Maryland 21215

Dear Committee:

I have clearly printed below the information you will need to process this request and affixed my signature to authorize the deduction of one day from my allotted sick time for use in joining the Sick Bank.

(Check One)

____ Name Did Not Appear on Open Enrollment Roster

____ New Hire              Entry Date:  __________________

____Other

______________________________________________________________

Position:__________________________________________________________

              Example: teacher, paraprofessional, service-related personnel, etc.

Payroll Location (School Assignment, etc.) #_______________

Social Security Number: _______ - _______ - __________

First Name: _________________________________________________________________

Last Name: _________________________________________________________________

Home Address:  _____________________________________________________________

                             City                                                   State                                 Zip Code

Home Telephone Number: _________________

Work Telephone Number: __________________

Sincerely,

Signature