Employee name:                                                                                                     
Job Title:                                                                    Hire Date:                             

Type of leave requested (if request is due to medical reasons, have your physician complete the "Physician's Statement" near bottom of page):

          ____ medical leave                             ____ pregnancy leave
          ____ family leave                               ____ military leave
          ____ other (explain):                                                                                      
                                                                                                                            

Start date:                                       Expected return date:                                  

Do you want to use accrued vacation time before unpaid leave?           Yes            No

If yes, total number of accrued vacation hours or days requested:                                   

LEAVE, IF GRANTED, MAY BE USED ONLY FOR THE PURPOSE DESCRIBED ABOVE. I understand that the use of leave for any other purpose will be grounds for disciplinary action including termination of employment. I understand I must return to work upon expiration of my leave of absence. I understand I must keep the office informed of a current address and telephone number of where I may be contacted.

Before returning from medical or pregnancy leave I will submit a health-care provider's verification of my fitness to return to work (including any limitations on the my ability to perform the essential duties of my job).

Employee signature:________________________________________ Date:____________

PHYSICIAN'S STATEMENT The above person is a patient in my care, and should be able to resume his/her duties on or about                                                       .

Physician's address:________________________________________________________
                          __________________________________________________________
Telephone No.: _______________________

Physician's signature:_____________________________________ Date: _________

EMPLOYER'S APPROVAL

  _____ Approved     _____ Denied (reason):                                                           
                                                                                                                       

Manager's signature:_____________________________________  Date:_____________