Leave Request

REQUEST FOR LEAVE OF ABSENCE

Today's Date(Required)

Name(Required)

First Last

Home Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Email(Required)

Company(Required)

Department(Required)

Position(Required)

Direct Supervisor(Required)

Employee ID

Date of Hire(Required)

Employment Status(Required)

Full Time

Part Time

Other

Please Specify

Leave Request Type(Required)

Initial Leave Request

Extension of Leave Request

Reason for Leave(Required)

Please select the appropriate option to indicate the reason for your leave request

Leave Start Date(Required)

Do You Know Your Leave End Date?(Required)

Leave End Date(Required)

Documentation

Max. file size: 512 MB.

Please attach any relevant Leave Request (Medical, Military, Education, Other) documentation. Insurance: Employee is responsible for arranging continuation of coverage; see the Benefits designate within your company to discuss policy and payments.

Signature(Required)

BY SIGNING THIS, I CERTIFY THAT THE INFORMATION PROVIDED IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.

Leave Request

REQUEST FOR LEAVE OF ABSENCE

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