REQUEST FOR LEAVE OF ABSENCE WITHOUT PAY
Name ____________________________________ S.S. # _____-_____-____
Address _____________________________________________________
Position ________________________________ Employment Date _______
Last Day to be Worked _______________ Return Date ______________
Request is made for leave of absence without pay for the following reason:
[ ] Disability [ ] Work Related Disability [ ] Educational Leave [ ] Military Leave
[ ] Personal Leave [ ] Pregnancy [ ] Other _____________________________________________________
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 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 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.
Warning:
These forms are provided AS IS. They may not be any good. Even if they are good in one jurisdiction, they may not work in another. And the facts of your situation may make these forms inappropriate for you. They are for informational purposes only, and you should consult an attorney before using them.
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