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Employee Request for Leave Form

Instructions:  Complete this from and click submit.  The form will be forwarded to the Human Resources Office.  

Employee Information

Type of Leave Being Requested

Certification (s) of medical need for leave, adoption/fostering certification, active duty documentation, call to duty documentation or proof of attendance for jury duty will be required.  

Amount of Leave

I request the leave be granted for the following period of time:

By submitting this form, I hereby certify that the information given above is true and correct to the best of my knowledge.  I understand that misrepresentation or omission of the reason for leave or any of the facts supporting the need for leave will result in denial of the leave and will subject me to discipline up to and including termination.