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.
