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Request For Leave Of Absence Without Pay HR-734 - Legal Forms

Request For Leave Of Absence Without Pay Form. This is a Legal Forms form and can be used in Employment .
 Fillable word Last Modified 4/23/2009
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REQUEST FOR LEAVE OF ABSENCE WITHOUT PAY Name ____________________________________ S.S. # _____-_____-____ Address _____________________________________________________ Position ________________________________ Employment Date _______ Last Day to be Worked _______________ Return Date ______________ Request is made for leave of absence without pay for the following reason: [ ] Disability [ ] Work Related Disability [ ] Educational Leave [ ] Military Leave [ ] Personal Leave [ ] Pregnancy [ ] Other _____________________________________________________ Leave, if granted, may be used only for the purpose described above. I understand that the use of leave for any other purpose will be grounds for disciplinary action including termination of employment. Employee Signature ___________________________ Date ____________ PHYSICIAN'S STATEMENT If the request for leave is due to medical disability, please have your physician complete the following statement: The above-named is a patient in my care, and is expected to be able to resume his usual occupation on or about __________________________. Physicians Address _____________________________________________________ Phone Number ___________________________ Physician's Signature _______________________ Date _____________ Approval: Department Manager: _______________________ [ ] Approved [ ] Denied Reason _______________________ Manager Signature ___________________________ Date _________ Personnel Manager __________________________ [ ] Approved [ ] Denied Reason ________________________ Manager Signature __________________________ Date __________ TO THE EMPLOYEE: You are expected to return to work upon the date of expiration of your leave of absence. Request for an extension of leave of absence must be made to the Personnel Department prior to the return date of your leave. You have the responsibility for maintaining contact, i.e., the address and phone number of where you may be contacted. American LegalNet, Inc. ©
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