Northern Virginia Community College
Leave Sharing Program Donor Form

I wish to donate the number of hours of annual leave indicated below. Donations must be made in 8-hour increments. I understand that I cannot reclaim my donated leave unless my leave donation has not yet been processed.

Date _____________________ Annual Leave Hours Donated _______________

Donor Name ___________________________________________________________

Donor SSN ____________________________________________________________

Division _______________________________________________________________

Recipient’s Name and Agency

______________________________________________________________________

Relationship ___________________________________________________________

(Complete only if inter-agency transfer)

______________________________________ ______________________

Donor Signature Date

______________________________________ ______________________

Leave Administrator Date Received

______________________________________ ______________________

Payroll Administrator Date Received