Leave Of Absence Packet Page 3
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3Leave Request Form
____________________________________
______________________________
Employee Name
Z number
____________________________________
______________________________
Title
Work Location
Work Phone
____________________________________
______________________________
Home Phone
Cell Phone
____________________________________
Anticipated Leave Dates:
Home Address
____________________________________
______________
______________
From
To
____________________________________
------------------------------------------------------------------------------------------------------------------------------
Type of Leave Requested:
Family Leave:
____________
____________
____________
Self (Personal Illness)
Family Member
Birth of Child
Military Leave:
____________
Personal Leave:
____________
Do you wish to use your Accrued Time:
Vacation Time:
_____
__________
__________
__________
Yes/No
Balance
From
To
Administrative Leave Time: _____
__________
__________
__________
Yes/No
Balance
From
To
Compensatory Time:
_____
__________
__________
__________
Yes/No
Balance
From
To
** Sick Time:
_____
__________
__________
__________
Yes/No
Balance
From
To
** Note: Must use all accrued sick time before going on State Disability.
The information contained on this form and the supporting documentation attached is true and
accurate to the best of my knowledge.
_________________________________________
Employee Signature
Date
Rev 1/813
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