Writing the Employee Leave Request Form document
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
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
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