REQUEST FOR LEAVE

Application for Leave
Name (Last, First, Middle Initial):
Position - Classification:
From: (Mo/Day/Yr./Hour)
To: (Mo/Day/Yr./Hour)
No. of Hours
Reason for Requesting Leave:
Type of Leave
Reason for Requesting Leave:
 Annual  "I understand that any leave authorized in excess of the amount available to me during the leave year will be charged to L.W.O.P."
Sick Without Pay  
Others (specify)
(If applying for sick leave) -
During this absence I was incapacitated for duty by:
  Personal Sickness
  Pregnancy and Confinement
  Off the Job Injury
  Undergoing Medical, Dental or Optical Examination or Treatment
  Required to take care of a member of my family with a contagious disease.
  (Give name of disease and circumstances of exposure)
Signature
Full Name:
Date       :

 
 
 
 
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