(By Employee)

I, (name of employee), hereby request a leave of absence effective (specify date) for the following reason (specify): I have been advised that my leave of absence will be (with or without pay).  I plan on returning by (specify date) or (state why it is impossible to predict a precise return date).

(Optional: Due to the medical nature of my leave, I agree to comply with all XYZ Employer policies and submit timely and accurate physician statements or be available to submit to a physical examination by a doctor designated by the Company as the Company may reasonably request.)

I have been advised and understand that if I am unable to return to work by (specify), the Company has the right in its sole discretion not to hold my job open until my return and I may either be re-employed in a different position or may lose the opportunity to continue my employment in any position if no replacement job is available or is not offered.

No other representations or promises regarding continued employment or job security have been made to me as I am an AT WILL employee, free to resign at any time and capable of being terminated at any time with or without cause.  I acknowledge that if I breach any of the representations contained hereinabove, or if my leave request is granted but the purpose or nature of the leave was misstated, XYZ Employer may discipline me up to or including immediate discharge.

EMPLOYER AUTHORIZATION

Request Approved:

Request Denied: (Specify Reason)
By:
Title:
Department:
Comments: