LEAVE APPLICATION Form-HR-001 Rev.

00

Application ID.
No.: Date:

Employee ID:
Name: Emp ID.:
Position: Assigned To: Date Appointed:

1. With exception of sick leave, Other Leave will not normally granted if application is not submitted 48 hours in advance, except.
2. Failure to resume duty after the leave period will be deemed negligence of duty and may be subject to summary dismissal.

LeaveAttributes:
Type: Unpaid Sick Marriage Bereavement Others_______________
No. Of Days requested: Leave Date: Return Date:
Home Tel. No.:

Justification for Leaves:

Supporting Documents, Medical Report, or Other Attachments:

Employee Certification & Acknowledgment:

I certify that the leave/absence requested above is for the purpose(s) indicated. I understand and Signature:
acknowledge that falsification of information on this form or delay in reporting maybe grounds for
Date:
disciplinary action, including termination.

Employee Department/Divisionproposal:
Name:

Date & Signature:

Disapproved: Justification:
 Original Disapproved Application to employee for notification
 Copy of Disapproved Application to employee file for record

HR Department Rep.: :Signature :Date

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