Leave Application

Complete the leave application and download the PDF to submit to your supervisor for approval.

LEAVE APPLICATION
Employee Name:
Position:
*Type of Leave	Bereavement Only - Relationship to Employee		# of Hours

	Hour	Month/Day/Year
Beginning:
Ending:
*Type of Leave	Bereavement Only - Relationship to Employee		# of Hours

	Hour	Month/Day/Year
Beginning:
Ending:
*Type of Leave	Bereavement Only - Relationship to Employee		# of Hours

	Hour	Month/Day/Year
Beginning:
Ending:
	By checking this box, I certify that all information on this form is correct. This checkbox represents my digital signature.
Date of Request:
Supervisor's Signature: _______________________________ Initials: ____________
Date: __________________

Check Agency Procedures Manual for Sufficient Prior Approval of All Types of Leave
*Types of Leave: Annual, Vacation, Hospital, Sick, Bereavement, Annual Buy Out, Without Pay, Other (Specify)