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Leaves Without Pay

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48 views2 pages

Leaves Without Pay

Uploaded by

muhammadumarkumo
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Office of Human Resources

30 Belmont Avenue

EMPLOYEE APPLICATION FOR LEAVE WITHOUT PAY

Employee: Smith ID Number:

Position: Department:

Hire Date: Date of Request:

CURRENT WORK SCHEDULE

Hours per Week: Days per Week: Weeks per Year:

Please check the appropriate leave type (either A or B), sign your name, fill in the details and forward this
form to your department head for his/her signature.

A. SHORT-TERM LEAVE WITHOUT PAY (up to 10 consecutive work days)


† I am requesting a short-term unpaid leave of absence under the provisions of the Leave Without
Pay Policy. I am not eligible for paid leave under the College's other leave plans, and have
exhausted all vacation and personal time. I have reviewed the policy and understand the impact on
my pay, job status, and benefits; I understand and accept my obligations under the policy.

B. LONG-TERM LEAVE WITHOUT PAY (11 days to 6 months)

† I understand that to qualify for this leave, I must have been employed by the College for a
minimum of 12 consecutive months in a regular position of half-time or more prior to the beginning of
the leave. I am requesting a long-term unpaid leave of absence under the provisions of the Leave
without Pay Policy. I am not eligible for paid leave under the College's other leave plans, and have
exhausted all vacation and personal time. I have reviewed the policy and understand the impact on
my pay, job status, and benefits; I understand and accept my obligations under the policy.

Begin Date: Return to Work Date:

Reason for Leave:

I understand that by requesting this leave of absence, I am committed to returning to work on the date
specified.

Employee Signature: Date:


DEPARTMENT HEAD

Comments:

† Approve † Request Denied

Signature Date

HUMAN RESOURCES

Signature Date

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