Reques t for Leave

Type of Leave: Sick: ___ Annual: ___ LWOP: ___

Name:_________________________ Date: __________

Start Date: Hour AM / PM Date

Type of Leave: Sick: ___ Annual: ___ LWOP: ___ _____:_____ __________

End Date: Hour AM / PM Date

Start Date: Hour AM / PM Date _____:_____ __________
_____:_____ __________
Total Hours of Leave: __________

End Date: Hour AM / PM Date

_____:_____ __________ Duties During My Absence Will Be Handled By:

Total Hours of Leave: __________ _____________________________________________

Signature: ____________________________________
Duties During My Absence Will Be Handled By:
Approval: Supervisor: _________________________
_____________________________________________
Date: ______________________________
Signature: ____________________________________

Approval: Supervisor: _________________________

Date: ______________________________

Re quest for Leav e

Name:_________________________ Date: __________