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Cortland County Personnel/Civil Service 60 Central Avenue Cortland NY 13045-2746 [PHONE REDACTED] www.cortland-co.org/personnel LAURIE LEONARD PAMELA ABBOTT PERSONNEL OFFICER DEPUTY PERSONNEL OFFICER SUBMIT TO THE PERSONNEL OFFICE REQUEST FOR TIME FROM EMERGENCY POOL I am requesting time from the Emergency Pool for the following reason and have attached the required medical documentation. I understand that the required medical documentation will be kept confidential. The Emergency Pool Committee will only receive a notification that the medical documentation has been received and evaluated. Name Title Department Standard work hours per week Reason Please check the box if the reason for the Emergency Pool request can be released to County employees to solicit donations for your request. All requests are subject to the Emergency Pool Policy. The policy is on the Personnel Department’s webpage. I attest that my injury and/or illness is/will not be eligible to be covered by 207-C, Worker’s Compensation, Social Security Benefits or Unemployment Insurance. I have received, read, understand and agree to abide by the Emergency Pool Policy. Signature Date