Appendix B

Dining Services Meal Program “Opt-Out” Form

Last Name, First Name (PRINT) Dining Services Unit and Campus Location

To:

Supervisor Date

I voluntarily request to opt out of the Dining Services Meal Program due to my current work assignment in a non‐dining facility where food is not served. I understand that should my work assignment change at any time to a dining facility where food is served, the Dining Services – Executive Director’s Office will reinstate my participation in the Dining Services Employee Meal Program, and the meal charges will be reinstated to coincide with the effective date of my transfer.

Supervisor’s Signature Employee’s Signature

Dining Services – Executive Director’s Office

Cc: Dining Services – Executive Director’s Office Office of University Labor Relations

Payroll Services

Employee Copy

URA‐AFT

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