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                                     [   ] Disability - Work Related

[   ] Educational Leave                       [   ] Military Leave

[   ] Personal 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.