Contract Packs / All Documents / Employee Leave Request Form

Company Name

Employee: First Last Job title of signator, authorized signature or signer.

Contract Job Title Department: Department Supervisor: Supervisor Leave Date(s) Leave Start Date: Start Date Leave Return Date: End Date Total Number of Work Hours:

Instructions: Supervisor must complete the following form and file it with the Human Resources Department.

Reason for Leave

Leave Benefit(s) 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 by 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

Employee and Supervisor are required to sign this Employee Leave Request in order to gain Company approval and to certify that all benefits requested by Employee are available. Upon approval by the Company, both Employee and Supervisor will receive written notification of said approval from the Company Human Resources Department. Please Note: Any accumulated Sick or Vacation Leave that the employee has accrued must be used prior to accepting Leave without Pay status.

Should the employee select Leave without Pay status, it is the sole responsibility of the employee to ensure that his or her Health and Medical coverage is continued. Employee should review the rights and responsibilities concerning Leave without Pay and the effect on Health and Medical Benefits prior to enacting Leave without Pay. Information concerning these rights and responsibilities may be found within the Company Human Resources Guide or by speaking with the Company Human Resources Department.

Employee Signature Date

Supervisor Signature Date

For Office Use Only

Approved By signator, authorized signature or signed

Human Resources Manager Date

Address Address City, State Postal Code

Phone Phone Number