LEAVE REQUEST FORM
I request hours of
(number of) (see list below *)
(time & date) (time & date)
I certify that sufficient leave is available to cover this absence (annual and sick leave only).
Justification, if applicable:
(supervisor’s signature) (date)
* Types of Leave include:
Leave Without Pay
Please return completed form to your Program Manager/Supervisor.
6720-A Rockledge Drive · Suite 100 · Bethesda, Maryland 20817 · Telephone: (240) 694-2000 · www.hjf.org