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LEAVE REQUEST FORM

Employee Name: ___________________________ Date: _________________________

Dates Requested: ___________________________ No. of Days: ___________________

Type of Leave: Vacation Leave Sick Leave

Other: Paid Leave (please state) _______________

Other: Unpaid Leave (please state) _____________

To be completed by Supervisor/Manager

Supervisor/Managers Name: _______________________________________________

Signature: _____________________________________ Date: _______________________

Days remaining for the year: ___________________________________________________

LEAVE REQUEST FORM (COPY)

Employee Name: ___________________________ Date: _________________________

Dates Requested: ___________________________ No. of Days:___________________

Type of Leave: Vacation Leave Sick Leave

Other: Paid Leave (please state) _______________

Other: Unpaid Leave (please state) _____________

To be completed by Supervisor/Manager

Supervisor/Managers Name: _______________________________________________

Signature: _____________________________________ Date: _______________________

Days remaining for the year: ___________________________________________________

01/07/16
v1.0

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