LEAVE REQUEST FORM

NAME: ________________________________________
OFFICE: ________________________________________
DATE: ________________________________________


TYPE OF LEAVE

ANNUAL: _______

SICK: _______

ADMINISTRATIVE: _______

OTHER: _______ REASON: ______________________________________

DATE OR DATES LEAVE REQUESTED (WORK DAYS)

__________________________________________________________________

__________________________________________________________________

TOTAL NUMBER OF HOURS: _______________________________________________


EMPLOYEE SIGNATURE: ____________________________________________________________


APPROVAL: __________________________________________________________________
(SIGNATURE OF AUTHORIZING OFFICIAL) (DATE)


DISAPPROVAL: ___________________________________________________________________
(SIGNATURE OF AUTHORIZING OFFICIAL) (DATE)

IF DISAPPROVAL, STATED REASON: _________________________________________________________

______________________________________________________

______________________________________________________

Copies of this request should be retained by the employee for their records and by management in the employee's office file.