Request For Leave Of Absence Without Pay {HR-734}

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. 251 www.FormsWorkFlow.com