| LEAVE APPLICATION |
|
Employee Name: |
|
|
Position: |
|
|
*Type of Leave |
Bereavement Only – Relationship to Employee |
# Days or Hours |
|
|
|
|
Hour |
Month/Day/Year |
|
Beginning: |
|
|
|
Ending: |
|
|
|
*Type of Leave |
Bereavement Only – Relationship to Employee |
# Days or Hours |
|
|
|
|
Hour |
Month/Day/Year |
|
Beginning: |
|
|
|
Ending: |
|
|
|
*Type of Leave |
Bereavement Only – Relationship to Employee |
# Days or Hours |
|
|
|
|
Hour |
Month/Day/Year |
|
Beginning: |
|
|
|
Ending: |
|
|
|
By checking this box, I certify that all information on this form is correct. This checkbox repesents my digital signature. |
|
Date of Request: |
|
|
| Supervisor’s Signature: _______________________________ Initials: ____________ |
|
| Date: __________________ |
| Download PDF |
| Check Agency Procedures Manual for Sufficient Prior Approval of All Types of Leave |
| *Types of Leave: Annual, Vacation, Hospital, Sick, Bereavement, Annual Buy Out, Without Pay, Other (Specify) |
