EMPLOYEE LEAVE REQUEST FORM

EMPLOYEE NAME	EMPLOYEE ID NUMBER	TODAY'S DATE
EMPLOYEE EMAIL	WORK PHONE	PERSONAL PHONE
DEPARTMENT NAME	SUPERVISOR NAME

LEAVE DETAILS
START DATE	END DATE	NUMBER OF HOURS REQUESTED	LEAVE CODE refer to key below or contact HR

EMPLOYEE NAME	EMPLOYEE SIGNATURE	DATE
SUPERVISOR NAME	SUPERVISOR SIGNATURE	DATE

LEAVE CODES enter description and ID for codes not listed
DESCRIPTION	CODE	DESCRIPTION	CODE
Vacation	VC	Jury Duty	JD
Sick	S	Workers Compensation	WC
Bereavement	BV	Family Medical Leave	FMLA
Leave Without Pay	LWOP	Personal Leave	PL

ADMINISTRATIVE USE ONLY	AMOUNT OF LEAVE APPROVED	LEAVE BALANCE REMAINING	UPDATED BY

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