REQUEST FOR LEAVE OF ABSENCE
This request is for Leave other than Family or Medical Leave All requests for
Leave of Absence must be accompanied by appropriate documentation.
Name _____________________________________________ Date _____/_____/_____
Department _____________________ Hire Date ____/____/____
Current length of Employment : ________________________________
Employee Payroll # _____________________
DETAILS OF REQUEST
Leave Date ____/____/____ Return Date ____/____/____
In cases other than government ordered or leave under the Family and Medical Leave Act, this Request for
Leave is made with the understanding of the following:
1. My current position may be eliminated during my leave of absence.
2. My absence may be filled by another employee.
3. In the event that my position is eliminated or filled by another employee, I may or may not be
considered for another position within the company.
4. In the event that a position is unavailable at the end of this absence, the company reserves the right to
terminate my employment.
5. In the event that I do not return to work on the date documented above, I understand that my position
my employment may be terminated, unless I filed an extension and it has been approved by my
employer, and signed by both parties.
Leave of Absence is covered by the company’s leave policy, a copy of which I have read and understand.
By signing this form, I understand and accept the conditions above.
Employee Signature ______________________________________________ Date _________________
Employer’s Signature _____________________________ Date __________
McKenzie Management • 877-777-6151•