City of Memphis Sick Leave Bank Distribution Form

Have you previously received sick leave from the Sick Leave Bank? *
Did you go by the same name? *

If no, please provide the name and date used during previous distribution request.

calendar
calendar
Is your current illness/injury/medical condition work-related? *
Did you file an on-the-job injury claim with the City of Memphis? *
calendar
Have you applied for Social Security disability? *
calendar
Are you currently approved for or receiving Social Security disability? *
calendar
Are you currently earning and/or receiving income from other employment? (excluding pensions) *
Have you applied for retirement from the City of Memphis? *
calendar
CERTIFICATION: (Please read and agree) *


Applicant Verification