W. Va. Code R. agency 126, tit. 126, ser. 126-157, app A
SABBATICAL LEAVE APPLICATION
Name:
Address:
Telephone:____________________ (Home) ___________________ (Business)
Work Location:
Job Classification:
Years employed by______________________County Schools:
Have you previously been granted sabbatical leave by__________________ County Schools?Yes ______ No If Yes, when?
Proposed dates of sabbatical leave: to
If completing a degree:
Name of institution in which sabbatical leave will be taken:
Address:
Contact Person:
Have you been admitted to the institution? ______Yes ______No
Date of acceptance:
(Please attach letter of assurance that you have been accepted.)
If conducting research or completing other professional development activities give a brief desciption. (Use an attached sheet.)
Please state briefly the benefit of the sabatical leave (a) to the school district and (b) to you. (Use an attached sheet.)
If my application for a sabbatical leave is favorably acted upon, I hereby agree to successfully complete such sabbatical leave under the terms and conditions that are prescribed by the Sabbatical Leave Policy.
Signature_______________________ Date
OFFICE USE ONLY
Date Received:
Approved______ Not Approved______ Funds Allotted:
W. Va. Code R. agency 126, tit. 126, ser. 126-157, app A