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

 
   
     
     
   
SOURCE: hrVillage.com
Human Resources