Leave Of Absence Request Form

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LEAVE OF ABSENCE REQUEST FORM
DATE(S) REQUESTED
HOURS UNAVAILABLE
TYPE OF LEAVE
_______________________________
_______ TO _______
____ PAID
_______________________________
_______ TO _______
____ UNPAID
_______________________________
_______ TO _______
____ SICK
_______________________________
_______ TO _______
_______________________________
_______ TO _______
_______________________________
_______ TO _______
_______________________________
_______ TO _______
_______________________________
_______ TO _______
_______________________________
_______ TO _______
_______________________________
_______ TO _______
_______________________________
_______ TO _______
NOTE: If hours go into more than one pay period, please complete a form for each pay period.
TOTAL NUMBER OF HOURS REQUESTED:
__________
PLEASE WRITE DOWN ALL SITES THAT THIS LOA IS FOR:
_____________________________________________________________________________________
_____________________________________________________________________________________
COMMENTS:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Employee Name (Please Print)
Employee Signature
Date
LEAVE APPROVED ____
_____________________________________________
LEAVE DENIED
____
Supervisor’s Signature
Date

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Parent category: Business
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