Request For Leave Of Absence Form printable pdf download

Request For Leave Of Absence Form

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 : ________________________________

Position ___________________________

Full Time

Part Time

Temporary/Seasonal

Employee Payroll # _____________________

DETAILS OF REQUEST

Leave Date ____/____/____ Return Date ____/____/____

With Pay

Without Pay

Reason:

Personal

Health

Government Required

Education

Other ___________

Details: ___________________________________________________________________

CONDITIONS

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.

Additional Conditions:

Leave of Absence is covered by the company’s leave policy, a copy of which I have read and understand.

Other ___________________________________________________________________.

By signing this form, I understand and accept the conditions above.

Employee Signature ______________________________________________ Date _________________

Approved

Denied

Employer’s Signature _____________________________ Date __________

McKenzie Management • 877-777-6151•

Request For Leave Of Absence Form