Request For Personal Leave Of Absence Without Pay printable pdf download

Request For Personal Leave Of Absence Without Pay

REQUEST FOR PERSONAL LEAVE OF ABSENCE WITHOUT PAY

If a leave is for the employee’s medical condition, for care of a newborn child, or for care of a spouse, parent or child with a serious medical

condition, please use the Request for Family or Medical Leave form.

Date: __________________________

TO: ______________________________________________

Immediate Supervisor

FROM: ____________________________________________

Employee ID: ____________________

Employee

RE:

PERSONAL LEAVE FOR ABSENCE WITHOUT PAY

I am requesting a personal leave of absence without pay for the period ________________ to ______________

for the reason of ___________________________________________________________________________.

**Attention COLT collective bargaining unit members: Under the COLT collective bargaining unit, if the personal

leave period exceeds ninety (90) days, your rights regarding re-employment shall be established in advance by mutual

agreement of the unit member and designated administrator(s). This will be set forth in writing as a condition of

approval of the leave. The letter MUST be attached to this form in order for your leave to be processed successfully.**

I have read and understand the applicable leave policies. I further understand that I must assume responsibility for

making arrangements with the Benefits Office to continue my employee benefits coverage.

SIGNATURES

____________________________________________________

Employee

Date