Application For Extended Leave Of Absence
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FIRE DEPARTMENT
CITY OF NEW YORK
APPLICATION FOR EXTENDED LEAVE OF ABSENCE
I.
EMPLOYEE INFORMATION
NAME (PRINT)
EMPLOYEE REF. #
CIVIL SERVICE TITLE
BUREAU/DEPARTMENT
WORK TELEPHONE #
HOME TELEPHONE #
HOME ADDRESS
CITY
STATE
ZIP CODE
II. TYPE OF LEAVE (Please Check One)
FAMILY AND MEDICAL LEAVE ACT (FMLA)
MEDICAL
CHILD CARE
PERSONAL
ADVANCED
MILITARY
DISCRETIONARY GRANT
III. DATES REQUESTED
NUMBER OF WORKING DAYS
HOURS
FIRST DAY/HOUR OF ABSENCE
LAST DAY/HOUR OF ABSENCE
/
/
/
/
AM
AM/PM
AM/PM
AM
MM
DD
YYYY
MM
DD
YYYY
IV. COMPENSATION
WITH PAY
WITHOUT PAY
V.
EMPLOYEE SIGNATURE
DATE
______________________________________________________
___________________
INSTRUCTIONS & REQUIRED DOCUMENTATION
This form must be completed for all absences that will exceed thirty (30) days. For detailed information regarding
extended leaves see the Time & Leave Manual or contact the Leave Unit at 718-999-0607/2956.
All requests, except Medical, must be submitted to your supervisor before submission to Bureau of Human
Resources, 9 MetroTech Center, Brooklyn, NY 11201.
Proper documentation must be attached. For required documents see Page 2 of this form.
BUREAU RECOMMENDATIONS
APPROVED
APPROVED
DISAPPROVED
DISAPPROVED
____________________________________
REMARKS
REMARKS ________________________________________
____________________________________
____________________________________
___________________________________________________
____________________________________________________
SUPERVISOR SIGNATURE (Print and Sign)
Date
BUREAU HEAD SIGNATURE (Print and Sign)
Date
HR USE ONLY
DOCUMENTATION ATTACHED:
DATE PACKAGE RECEIVED: __________________________
Rev 05/12
HR-07-02
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