CITYMD SURGICENTER, INC.

LEAVE REQUEST FORM

Employee’s Name: Department:

Immediate Supervisor: Date Filed:

Type of leave:
 Leave Without Pay Emergency Leave
 Vacation leave Maternal Leave
 Sick Leave Paternal Leave
 Bereavement Leave Other: _________________________

Dates Requested: From: ____________ To _______________

Purpose of leave:

Employee Signature: Manager/Supervisor Approval:

 Approved
 Rejected

Signature: _________________________________

CITYMD SURGICENTER, INC.

LEAVE REQUEST FORM
Employee’s Name: Department:

Immediate Supervisor: Date Filed:

Type of leave:
 Leave Without Pay Emergency Leave
 Vacation leave Maternal Leave
 Sick Leave Paternal Leave
 Bereavement Leave Other: _________________________

Dates Requested: From: ___________ To _____________

Purpose of leave:

Employee Signature: Manager/Supervisor Approval:

 Approved
 Rejected

Signature: _________________________________