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Leave of Absence Request Form

This does not circumvent the employee's responsibility to personally notify their branch manager of their need for a leave of absence.

Please note: This form is for United States employees only.

LEAVE OF ABSENCE INFORMATION
Employee Name: *
Employee Phone Number: *
(xxx) xxx-xxxx
Employee ID Number: *
Date of Hire: *
(mm/dd/yyyy)
Branch Number and/or Location: *
Country: *
Manager: *
Manager Email Address: *
Type of Absence Requested:
FMLA
Maternity/Paternity
Medical
Personal
Military
Other
Dates of Absence
To:
(mm/dd/yyyy)
From:
(mm/dd/yyyy)
Requests for leave of absences must be provided thirty (30) days advance notice when the leave is "foreseeable", I.E. Pregnancy, elective surgery.  When the leave is not foreseeable, the employee must request a leave "as soon as practicable” under the circumstances, which usually means within one or two business days.
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NOTIFICATION
Would you like to use your available vacation time to supplement your personal Leave or your Short-term Disability Claim?
Yes
No
If yes, please enter how many hours you would like to use?
Note: Once you have submitted your claim, a notification will be sent to the Human Resources Department and your Manager.
Anti-Spam Question: *
What is 1+4?
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