Leave Of Absence Application

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 may result in loss of coverage.

No other representations or promises regarding continued employment or job security have been made to me as I am an at-will employee, free to resign at any time and capable of being terminated at any time with or without cause.  I acknowledge that if I breach any of the representations contained hereinabove, or if my leave request is granted but the purpose or nature of the leave was misstated, the company has the right to discipline me up to and including immediate discharge.

Employee Signature: ______________________________________Date :____/____/____

Supervisor Signature: ______________________________________Date :____/____/____