Leave Request Form

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RMBL Leave Request
Date: ________________
Employee’s Name: (please print): ____________________________________________
Supervisor’s Name: (please print): ____________________________________________
I request leave from RMBL employment on the following date(s):
_________________________________________________________________________
Days of leave taken (to date) during current calendar year, prior to above requested dates:
_________________________________________________________________________
______ This leave request is paid, as per employee’s contract, and does not exceed allowed
leave. Salary is not reduced.
______ This leave request is NOT paid, as per employee’s contract, and exceeds allowed
leave. Salary is reduced by the following dollar amount or number of days: (please explain):
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Employee’s Signature
Date
__________________________________________________________________________
Supervisor’s Signature
Date

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