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IT, web, Internet, software, hardware, media, multimedia, photography, tech, information, technology, computer, business, company, pre-written, legal, contract, agreement, documents, templates, boilerplate, form, outline, text, terms, recitals hr Company Employee Leave Request CurrentDate Employee ContractFirstName ContractLastName Job title signator authorized signature signer ContractJobTitle Department Department Supervisor Supervisor Leave Date Leave Start Date StartDate Leave Return Date EndDate Total Number Work Hours Instructions Supervisor must complete the following form and file with the Human Resources Department Reason for Leave Leave Benefit Used Please check all that apply Vacation Pay Sick Pay Personal Leave Comp Time Leave without Pay Bereavement Jury Military Duty Maternity Family Leave FLMA Leave Other Notes Leave Benefit Deductions Hours verified Human Resources Vacation Pay hours Sick Pay hours Compensatory Time hours Personal Days hours Leave without Pay hours Bereavement hours Jury Military Duty hours Maternity Leave hours FLMA Leave hours Vacation Pay hours Sick Pay hours Compensatory Time hours Personal Days hours Leave without Pay hours Bereavement hours Jury Military Duty hours Maternity Leave hours FLMA Leave hours Notes Employee and Supervisor are required sign this Employee Leave Request order gain Company approval and certify that all benefits requested Employee are available Upon approval the Company both Employee and Supervisor will receive written notification said approval from the Company Human Resources Department Please Note Any accumulated Sick Vacation Leave that the employee has accrued must used prior accepting Leave without Pay status Should the employee select Leave without Pay status the sole responsibility the employee ensure that his her Health and Medical coverage continued Employee should review the rights and responsibilities concerning Leave without Pay and the effect Health and Medical Benefits prior enacting Leave without Pay Information concerning these rights and responsibilities may found within the Company Human Resources Guide speaking with the Company Human Resources Department Employee Signature Date Supervisor Signature Date For Office Use Only Approved signator authorized signature signer Human Resources Manager Date Address1 Address2 City State PostalCode Phone WorkPhone
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