AFSCME Local 1981

PROCEDURES FOR REQUESTING DONATIONS

Name of Member receiving donation:______________________________________

Address:_____________________________________________________________

Illness:______________________________________________________________

Date Leave will expire:_________________________________________________

Name of Authorized Fund:_______________________________________________

Address:_____________________________________________________________

Phone Number:_______________________________________________________

Contact Person:_______________________________________________________

Name of Person requesting donation:______________________________________

Address:_____________________________________________________________

Phone Number:_______________________________________________________

Please Note:  A letter on Original Letterhead must be submitted from the

Organization which will be setting up the fund.

Rev:11/05