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EMPLOYEE LEAVE REQUEST FORM

Employee Name ______________________ Date _________________


Department ______________________
Position ______________________
REASON FOR LEAVE
Vacation Civil Leave/Jury Duty Military
Sick – Self Sick – Family Sick – Dr. Appointment
Worker’s Comp Family and Medical for __________________
Leave of Absence Funeral – Relationship __________________
Other _____________________________________________________

LEAVE REQUESTED
From ________________________ To __________________________

To be filled-out by HR
With Pay Without Pay Remaining Leave Credits: _______

Approved by:

JIM RYAN E. CATIAN, MBA, SPHRI


Human Resource Manager

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