Leave of Absence Request Form

Name, Employee ID:, Department:, Position:, Reason for Leave: (for Sick Leave and Personal Leave), Emergency Contact Name, Emergency Contact Relationship, Emergency Contact Phone Number

Type of Leave

Start Date, End Date, Date of Application

Number of Days requested

Please attach any supporting documents (i.e. medical certificates, doctor's note) for sick leaves with more than 3 days duration

Employee's Signature