WPC, ] 99!;]&/D=SgwU.rcDhUU`!DQ-*&tTa2 0BRh+MRS5F9 A3ȃǞGI JzyP)zNzT!0(KM_x,# n4'r%9]Zĝ0!*ʤ|BT:S;ܱޗwcsI)JAsXKŨgw r5Diz{yx>=f K2Pew:2U. 0 0 0 0 0 0) 0H 0g 0 0  0  0  0  0  0  0  0  0   0  0 & 0 2 0 > 0 J 0 V 0 b! 0 n" 0 z# 0$U >% 0<% 0+& 1s/'' 0'#h(UN1+ %+M+(+N+ 1u+ 72(,^ Z,wf,4j,~, m,<6X9`(Courier' UI,S-LOA twilson.0Melissa T. Francis .   2a+a 0_level1   , >4X` hp x (#%>23  ..   >4XX` hp x (#%>  2a+a 0_level2   X >4X` hp x (#%>23  ..   >4XX` hp x (#%>  2a+a 0_level3    >4X` hp x (#%>23  ..   >4XX` hp x (#%>  2a+a 0_level4    >4X` hp x (#%>23  ..   >4XX` hp x (#%>  2a+a 0_level5    >44X` hp x (#%>23  ..   >4XX` hp x (#%>  2a+a 0_level6    >4` X` hp x (#%>23  ..   >4XX` hp x (#%>  2a+a 0_level7   4 >4 X` hp x (#%>23  ..   >4XX` hp x (#%>  2a+a 0_level8   ` >4 X` hp x (#%>23  ..   >4XX` hp x (#%>  2a+a 0_level9    >4 X` hp x (#%>23  ..   >4XX` hp x (#%>  2aa 0_levsl1   , >4X` hp x (#%>23  Ԁ   >4XX` hp x (#%>  2aa 0_levsl2   X >4X` hp x (#%>23  Ԁ   >4XX` hp x (#%>  2aa 0_levsl3    >4X` hp x (#%>23  Ԁ   >4XX` hp x (#%>  2aa 0_levsl4    >4X` hp x (#%>23  Ԁ   >4XX` hp x (#%>  2aa 0_levsl5    >44X` hp x (#%>23  Ԁ   >4XX` hp x (#%>  2aa 0_levsl6    >4` X` hp x (#%>23  Ԁ   >4XX` hp x (#%>  2aa 0_levsl7   4 >4 X` hp x (#%>23  Ԁ   >4XX` hp x (#%>  2aa 0_levsl8   ` >4 X` hp x (#%>23  Ԁ   >4XX` hp x (#%>  2aa 0_levsl9    >4 X` hp x (#%>23  Ԁ   >4XX` hp x (#%>  2aa 0_levnl1   , >4X` hp x (#%>23     >4XX` hp x (#%>  2aa 0_levnl2   X >4X` hp x (#%>23     >4XX` hp x (#%>  2aa 0_levnl3    >4X` hp x (#%>23     >4XX` hp x (#%>  2aa 0_levnl4    >4X` hp x (#%>23     >4XX` hp x (#%>  2aa 0_levnl5    >44X` hp x (#%>23     >4XX` hp x (#%>  2aa 0_levnl6    >4` X` hp x (#%>23     >4XX` hp x (#%>  2aa 0_levnl7   4 >4 X` hp x (#%>23     >4XX` hp x (#%>  2aa 0_levnl8   ` >4 X` hp x (#%>23     >4XX` hp x (#%>  2aa 0_levnl9    >4 X` hp x (#%>23     >4XX` hp x (#%>  <l\:Default ParaS\  `&Times New RomanSXXXC<6X9`(CourierC\  `&Times New Roman<:Footnote Ref2x+V 0Level 1         >48X` hp x (#%>23  ..  >4XX` hp x (#%>   35;CKS[ck1a.a.aa.aa.aa.aa.aa.aa.a#|x( $XX..      &XnXX&XXXX&XnHP LaserJet 4100 Series PCL,,,,0(9 Z6Times New Roman Regular&X3#37=CIQYag1.a.i.(1)(a)(i)1)a)+i)=Q2 T+2:i+00U $ !XX..      &X{XX&XX'XX&X{  _       XX3X p x (#%X3וXX']ו_UI,S_ԄLOAQ X{X] UNIVERSITYOFLOUISIANASYSTEM  X ]XX{(11/96)X{X]Q  REQUESTFORLEAVEOFABSENCE > QANDSABBATICALAGREEMENT  $ N4XX` hp x (#%XX%N! X$%XXX%!]XX{INSTITUTION:$$N$  H4XX` hp x (#%X$HNAMEOFEMPLOYEE:________________________________________________SOCIALSECURITYNO._________________________  TITLE:_________________________________DEPARTMENT:______________________________________________________________  HIGHESTDEGREE:__________________BIRTHDAY:Month򀀀󀀀Day򀀀󀀀Year򀀀󀀀Age:___________   NUMBEROFCONSECUTIVEFISCALYEARSACTIVESERVICEINLOUISIANA:______________________________________________    NUMBEROFSEMESTERSOFACTIVESERVICEATTHISINSTITUTION: ____________________________________________________    PURPOSEOFLEAVEREQUESTED(Checkone):    B   XK4X` hp x (#%XXX%Ka.  ProfessionalorCulturalImprovement__________________   b.  Rest&Recuperation_________________(Statementsfromtwophysiciansmustbeattached.)    " (03+/ /""    ,XK4X` hp x (#%XX%K    X,  K4X` hp x (#%XX%K: 2  c  .3      Military_________________________: M ݌   Ќ  XX$ XX%XX%$    K4X` hp x (#%XX%Kd.  Other(Specify)_________________________ p   B   XK4XX` hp x (#%XX%KTYPEOFLEAVEREQUESTED(CheckOne): ^  xK4X` hp x (#%XXX%Ka.WithPay_____________Amount$____________________b.WithoutPay______________ `  xK4XX` hp x (#%XX%KLENGTHOFLEAVEREQUESTED(Numberofweeks): __________________ b  EFFECTIVEDATESOFLEAVE:Beginning_______________________Ending_______________________ d ! X$%XXX%!MANNERINWHICHTHISLEAVE,IFGRANTED,WILLBESPENT:$$N$ f $$N$$$N$H4X` hp x (#%X$H  IhavereviewedtheRULES[Bylaws,andPoliciesandProcedures]oftheUNIVERSITYOFLOUISIANABOARDOFTRUSTEES,at l$ ChapterIII,SectionV,pertainingtoLeavesofAbsenceandherebyagreetocomplywiththeprovisionsenumeratedtherein. p%   N4XX` hp x (#%XX%N6X p x (#%XXX%6________________________________  _______________________________________________________ p' 0X x (#%XX%033ӀDateofApplication  SignatureofApplicant t( ! X$%XX%!33 $$N$H4XX` hp x (#%X$H PRIORLEAVERECORDFROMTHISINSTITUTION(Tobecertifiedbytheinstitution):  * 6X p x (#%XXX%6DateofLastLeave:_______________________________________  LengthofLastLeave:________________________________________ ,   3X x (#%XX%3TypeofLastLeave:WithPay_________________  Amount$____________________  WithoutPay__________________  .   ' X$%X X%' $$N$  K7XX` hp x (#%%X$K APPROVALBYHEADOFDEPARTMENT:  J0 d XL   3X2 x (#%XXX%3_______________  ____________________________________________________ 2 ________________________________________  X2 0XN  (#%X2X%0ӀDateApproved N Signature  Department \!3 6X x (#%XN  (#%6DepartmentHeadmustincludealetterofrecommendationwiththisapplicationwhenitisforwardedtotheappropriateDeanandVicePresident. "\ 5 ' X$%X X%' $$N$  -XX` (#%X$- APPROVALBYDEANANDVICEPRESIDENT:   $!7 BX 7p x (#%XX` (#%BSignature:_______________________________________________ 7 Signature:________________________________________________ d% #9 Deanof_________________________________________________ 7 VicePresidentfor__________________________________________ f&$; Date:___________________________________________________ 7 Date:____________________________________________________ h'%=   $ X$%X7X%$ $$N$  -XX` (#%X$- APPROVALBYTHEHEADOFTHISINSTITUTION:  )&@ 6X (#%XX` (#%6______________________________  ___________________________________________________ *'B 3Xx (#%X (#%3ӀDateApproved  Signature *l(C   ' X$%XxX%' $$N$  -XX`X (#%X$- APPROVALBYTHEUNIVERSITYOFLOUISIANASYSTEM:  ,)E 6X (#%XX`X (#%6______________________________  ____________________________________________________ -*G 6X x (#%X (#%6ӀDateApproved  SignatureofthePresident -r+H   ' X$%X X%' $$N$  0Xp x (#%X$0 Q! ContinuedonReverseSide "/,J   N4XX` hp x (#%XpX%NY ] /v-K ЇUNIVERSITYOFLOUISIANASYSTEM ~ REQUESTFORLEAVEOFABSENCE = ANDSABBATICALAGREEMENT  T   ] Y  8  H1r` hp x (#%XXX%H(Instructions: r Pleaseindicatewithacheckmarkthepaystatusofyourleave,answeranyquestionspertainingtoyourstatus,andsignyourname k alongwiththedate.)    8N4XX` hp x (#%rX%N 1.  OFFICIALSABBATICALLEAVEWITHFRACTIONALPAY(75%ofpresentsalary) _____________  o  Duringaperiodofofficialleavewithfractionalpay,ahigherpercentageofretirementwithholdingwillbeassessedagainstyourfractionalpay(i.e.,   youwillbeassessedasifyouwereearning100percentofyourpresentsalary)toallowforfullretirementcreditduringtheofficialleaveperiod.  s  Theinstitutionwillpayfullemployer'sshare(UniversityofLouisianaSystemBoardofTrusteesPoliciesandProceduresManualatChapterIII, w   SectionV). #  Theleavepayshallbedistributedovertheentireperiodofthatleave. {#  Inacceptingthisleaveofabsencewithpay,IunderstandthatIassumealegalobligation,aslistedinActs1991,858(R.S.17:3328)toreturntothis { institutionforatleastoneyearoffurtherservice.Failuretoreturnthesemesterimmediatelyfollowingthesabbaticalwillresultinrepaymentofall ' sabbaticalleavepayreceived,unlessotherwisedeterminedbytheBoard. +  II.  OFFICIALLEAVEWITHOUTPAY_____________  / Duringaperiodofofficialleavewithoutpay,underthepresentlaw,youcannotmakecontributionsofyourshareand/ortheemployer'sshareofthe  salaryyouwouldhavebeenpaidbytheinstitutionduringthatperiodofleave. 3 Inordertopurchasethistime,youmustconsultwithyourrespectiveRetirementSystem. !  X $  X OTHERPROVISIONS  ;% Iamawareoftheprohibitionagainstdualappointmentsordualemploymentasdescribedin_LSA_ԄR.S.42:63.Thisstatuteprovidesthatnoperson ' holdinganelectiveoffice,appointiveoffice,oremploymentinanyofthebranchesofstategovernmentorofapoliticalsubdivisionthereofshallat ?( thesametimeholdanotherelectiveoffice,appointiveoffice,oremploymentinthegovernmentofaforeigncountry,inthegovernmentoftheUnited C) States,orinthegovernmentofanotherstate. * Ifullyunderstandtheabovestatements.  - 0Xp x (#%XXX%0________________________ p ______________________________________________ O$!2 -X x (#%XpX%-ӀDate  Signature,ApplicantforLeave $"3 N4XX` hp x (#%X X%N 0X  x (#%XXX%0APPROVED:________________ ________________________________________  UniversityofLouisianaatLafayette c. ,A 0XIx (#%X  X0  Date I President x Institution /,B  !X%XIxX! %%P% /c-C   0X p x (#%%X%0 X{X]X'XXX{N4XX` hp x (#%XpX%N