REQUEST FOR LEAVE OF ABSENCE WITHOUT PAY
Name ____________________________________
S.S. # _____-_____-____
Address ______________________________________________________________
Position ________________________________
Employment Date _______
Last Day to be Worked _______________
Request is made for leave of absence without pay, reason follows: [ ] Disability [ ] Educational Leave [ ] Personal Leave [ ] Disability - Work Related [ ] Military Leave [ ] Pregnancy
[ ] Other ________________________________________________
Start Date ______________________ Return Date ______________
Purpose __________________________________________________
Leave, if granted, may be used only for the purpose described above. I understand that the use of leave for any other purpose will be grounds for disciplinary action up to and including termination of employment.
Employee Signature ___________________________
Date ____________
PHYSICIAN'S STATEMENT
If the request for leave is due to medical disability, please have your physician complete the following statement:
The above-named is a patient in my care, and is expected to be able to resume his/her usual occupation on or about _____________________________________________________________________
Physicians Address ______________________________________________________
Phone Number ___________________________
Physician's Signature _______________________
Date _____________
Approval:
Department Manager: _______________________
[ ] Approved
[ ] Denied
Reason _______________________
Manager Signature ___________________________
Date _________
Personnel Manager __________________________
[ ] Approved
[ ] Denied
Reason ________________________
Manager Signature __________________________
Date __________
TO THE EMPLOYEE: -You are expected to return to work upon the date of expiration of your leave of absence.
-Request for an extension of leave of absence must be made to the Personnel Department prior to the return date of your leave. -You have the responsibility for maintaining contact, i.e., the address and phone number of where you may be contacted.