Employee Name: _________________________________Date of request: ____/____/____ Please print I am requesting a leave of absence effective _____/_____/_____ for the following reason: __________________________________________________________________________________________________________________________________________________ I have been advised that my leave of absence will be without pay. I plan on returning to work on _____/_____/_____ I understand that when I return to work, I will be restored to my current position or a substantially equivalent position. I also understand that while I am on any type of unpaid leave of absence, other than Family Medical Leave, I will be responsible for paying the total premiums for my benefits coverage for myself and for my dependents. Failure to do so […]