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Leave Request
REQUEST FOR LEAVE OF ABSENCE
Today's Date
*
MM slash DD slash YYYY
Name
*
First
Last
Home Address
*
Street Address
Address Line 2
City
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Texas
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Armed Forces Americas
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State
ZIP Code
Phone
*
Email
*
Company
*
Department
*
Position
*
Direct Supervisor
*
Employee ID
Date of Hire
*
MM slash DD slash YYYY
Employment Status
*
Full Time
Part Time
Other
Please Specify
Leave Request Type
*
Initial Leave Request
Extension of Leave Request
Reason for Leave
*
Select one
Medical Leave
Military Leave
Personal Leave
Please check the appropriate box to indicate the reason for your leave request
Medical Leave
*
Health Condition (Self)
Health Condition (Family Member)
Pregnancy or Pregnancy Related
Job Related Injury/Illness
All Medical Leave requests require a signed Medical Certification from an approved Medical Practitioner
Expected Delivery Date
MM slash DD slash YYYY
Injury Date
MM slash DD slash YYYY
Military Leave
*
Active Duty (Attach Military Orders)
Personal Leave
*
Education (School Verification Required)
Other
Specify Reason
Leave Start Date
*
MM slash DD slash YYYY
Do You Know Your Leave End Date?
*
Yes, I know when my leave will end
No, I don't know when my leave will end
Leave End Date
*
MM slash DD slash YYYY
Documentation
Max. file size: 64 MB.
Please attach any relevant Leave Request (Medical, Military, Education, Other) documentation
Insurance: Employee is responsible for arranging continuation of coverage; see the Benefits designate within your company to discuss policy and payments.
BY SIGNING THIS, I CERTIFY THAT THE INFORMATION PROVIDED IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.
Signature
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Comments
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