EMPLOYEE LEAVE REQUEST FORM
Employee Name
______________________
Department
______________________
Position
______________________
Date _________________
REASON FOR LEAVE
Vacation
Civil Leave/Jury Duty
Military
Sick – Self
Sick – Family
Sick – Dr. Appointment
Worker’s Comp
Family and Medical for __________________
Leave of Absence
Funeral – Relationship __________________
Other _____________________________________________________
LEAVE REQUESTED
From ________________________ To __________________________
To be filled-out by HR
With Pay
Without Pay
Remaining Leave Credits: _______
Approved by:
JIM RYAN E. CATIAN, MBA, SPHRI
Human Resource Manager