Free Request for Leave of Absence Form

This Leave of Absence Request is used by an employee when asking for a leave of absence from his or her job. This form contains the employee’s name, requested dates of leave, type of absence and purpose for the leave of absence. This Leave of Absence Request form must be signed by the employee and approved by the employer.

Disclaimer:This was not drafted by an attorney & should not be used as a legal document.

Leave of Absence Request Form

Date: ________________________

Name: _______________________
ID#: _________________________

Department: __________________

Leave Requested: ______________ through ______________

Returning Date: ______________

Type of Leave/Absence: __________________________________
Purposes: ________________________________________________

I hereby request leave of absence from duty as indicated above and certify that such leave is requested for the purpose(s) indicated. I understand that any falsification on this form may be grounds for disciplinary action, including removal.

__________________________________ Date____________
Signature of Employee


__________________________________ Date____________
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