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Leave Request Form

This leave request form requires employees to provide information about requested time off including number of days, dates, and reason for leave. The employee must sign acknowledging they will first use accrued sick and vacation days during leave and any remaining time will be unpaid. Management will then approve or deny the request and note any remarks before human resources tracks remaining leave balances.

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Toya Nonyah
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1K views1 page

Leave Request Form

This leave request form requires employees to provide information about requested time off including number of days, dates, and reason for leave. The employee must sign acknowledging they will first use accrued sick and vacation days during leave and any remaining time will be unpaid. Management will then approve or deny the request and note any remarks before human resources tracks remaining leave balances.

Uploaded by

Toya Nonyah
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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LEAVE REQUEST FORM

Required for Full-Time employees working 30 hours + per week

Employee Name: ________________________ Branch: _________ Title: _______________________

SECTION I: DESIRED LEAVE DATES


I am requesting the following dates off duty:

# of Days: ______ Date(s): from____________ to_____________ ❏ Full Day ❏ Half Day

# of Days: ______ Date(s): from____________ to_____________ ❏ Full Day ❏ Half Day

# of Days: ______ Date(s): from____________ to_____________ ❏ Full Day ❏ Half Day

SECTION II: REASON FOR REQUESTED LEAVE


❏ Vacation ❏ Sick Leave ❏ Bereavement ❏ Birthday

❏ Personal ❏ FMLA ❏ Other: _____________________________


Notes: ____________________________________________________________________________
__________________________________________________________________________________
SECTION III:
I understand I will be required to use my accrued sick and vacation days if I am provided such, as part of my leave of
absence. After I have exhausted my sick and vacation days, I understand the remainder of the leave will be without pay.
I also understand that if I fail to return to work after the expiration of the leave, I will be terminated unless prior notice
has been provided to the company extending my leave.

Employee Signature: __________________________ Submission Date:______________

TO BE COMPLETED BY MANAGEMENT

The above request has been: ❏ Approved ❏ Denied


Remarks:_________________________________________________________________________

Manager/Supervisor Signature: _____________________________ Decision Date: _____________

HUMAN RESOURCE DEPARTMENT

Remaining Leave Balance: ______hrs. ______hrs. ______hrs. ______hrs. ______hrs.


Vacation Sick Personal Birthday
Remarks:_________________________________________________________________________

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