Leave of Absence Request

Name: Date:

Job Title: Department:

Forwarding Address:

Telephone: Mobile Phone:

Other phone:

Type of Leave

Medical (Attach required Certification) Family: Child Spouse, or Parent

Personal Military Other

I request approval of a leave of absence from to for the purpose of:

I understand that if I fail to return to work on the return date, my employment will be terminated.

I understand that prior to the leave, I must make arrangements to continue insurance coverage, if I am

eligible.

Employee Signature Date

Conditions of Leave:
(Job Guarantee, Maximum Length of Leave, Insurance Coverage, Benefits Accrual, Review Dates, etc.)

Approved By: Date

Approved By: Date

Approved By: Date