Memorandum  

To:       President
From:   
Date:    
Re:        Request for Leave without Pay of ______ Days

I am requesting a leave without pay for ______ days, beginning on ________ and ending on ________.  The reason I am requesting this leave is:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

Thank you for your consideration of this request.

____________________________________
Employee Signature

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Supervisor: 

Requests for leave without pay are considered on an individual basis, taking into consideration the reason for and urgency of the request, the ability of the department to provide coverage for the absence, and the employee's length of service and work record.  Please identify criteria for approval or denial.
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

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Human Resources:

Recommends [   ] approval         [    ] denial

____________________________________________________
Signature                                                                      Date

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President:

[   ] Approve  [   ] Deny 

____________________________________________________
Signature                                                                      Date

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Return to Human Resources

CONFIDENTIAL