Sample Request for Leave Form

Employee Name: ______________________________

Department: __________________________________

Social Security Number: _________________________

Date of Request: _______________________________

Leave Category Requested
_____ Paid Leave
_____ Unpaid Leave
_____ Other (Explain:____________)

Reason for Leave
_____ Vacation/Personal Leave
_____ Ill Family Member (Relationship_____________)
_____ Employee's Own Illness
_____ Care for New Child
_____ Other (Explain:____________)

Beginning Date of Leave: __________________________

Ending Date of Leave: ____________________________

Address During Leave: ____________________________

Phone No. During Leave: __________________________

Employee Signature: _____________________________

Special Circumstances (Explain):
______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________