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Print State of California Department of Human Resources CalHR 875 Rev. 6/2012 Reset ANNUAL LEAVE-SICK LEAVE/VACATION ELECTION FORM Employee Name Employee Identification Number/Social Security Number last four digits Department/Location Unit Number Work Phone Number EMPLOYEES NOT COVERED BY SEIU BARGAINING UNITS I elect to participate in the following leave program effective the first day of the pay period this election is received by my personnel.

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