Leave Of Absence Request Form. Board Determination

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Leave of Absence Request Form:
Date of Request: ____________________
Circle one: New
Request Extension of Approved LOA
Circle one:
Meetings Only
Full Leave
Member Name: _________________________________________________________
Request start and end date: _______________________________________________
Reason for request (please give as much detail as possible):
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Member Signature / Date:_________________________________________________
Submit completed request to RJC Secretary.
Board Determination:
RJC Board consideration date: _______________________
Determination: Approved Disapproved
Special Board requests:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
RJC Secretary Signature: _________________________________________________
RJC President Signature
: ______________________________________________________

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