APPLICATION FOR PERSONAL LEAVE OF ABSENCE

Employee requesting leave: __________________ Job Title: _____________________

Department: _______________________

Hire Date: _________________________

First day of leave: ___________________

Last day of leave (estimate if medical): ________________________

Date of Request: ____________________

Reason for request: _______________________________________________________

________________________________________________________________________

Conditions of the Leave

Leaves of absence are granted subject to conditions. Your signature of this request will indicate that you have read and fully understand each of these provisions. PLEASE READ CAREFULLY AND ASKY ANY QUESTIONS YOU MAY HAVE BEFORE SIGNING THIS FORM.

1. Failure to return on or before the date of expiration of a personal leave will be considered a voluntary quit effective on the last day actually worked.

2. Personal leave may be cancelled at any time upon two (2) weeks advance notification to report to active service. Failure to report will be considered a voluntary quit.

3. Use of the leave for any purpose other than indicated on this request may result in termination of employment.

___________________________________________ ________________________

Employee’s Signature Date

___________________________________________ ________________________

Department Approval Date

___________________________________________ ________________________

General manager’s Approval Date

cc: Employee

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