|
Leave
of Absence Request Form
|
|
|
|
__________________________________
|
|
__________________
|
Employee
Name
|
|
Date
|
|
|
|
__________________________________
|
|
|
Employee
ID Number
|
|
|
|
|
|
Type of Leave of Absence
|
[ ]
|
Medical |
[ ]
|
Military |
[ ]
|
Personal |
[ ]
|
Family Medical Leave |
[ ]
|
Others __________________
|
|
|
|
|
|
|
__________________________________
|
|
__________________
|
Start Date
of Leave
|
|
Return
to Work Date
|
|
|
|
All medical Leaves of Absence require
certification from a doctor to return to work.
|
|
|
|
__________________________________
|
|
__________________
|
Employee
Signature
|
|
Date
|
|
|
|
__________________________________
|
|
__________________
|
Supervisor
Signature
|
|
Date
|
|
|
|
__________________________________
|
|
__________________
|
Manager
Signature
|
|
Date
|
|
|
|
|
|
|
Route to:
[ ]
Timekeeping
[ ]
Payroll
[ ]
Benefits
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|