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.