| 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 |
