Change of Status Form

CHANGE OF STATUS REQUEST

(Leaves of Absences)
Name:*

First NameLast Name
Email*
example@example.com
What is your Change of Status Request?*
Effective Date of Request:*

MonthDayYear
Date
Expected Date of Return: *

MonthDayYear
Date
Response to Request for Change of Status
Enter Password to Respond to Request:
SUBJECT TO THE FOLLOWING CONDITIONS, your request for leave is:
APPROVEDNOT APPROVED
WITH PAYWITHOUT PAY
Leave will start on:

MonthDayYear
Date
Leave will end on:

MonthDayYear
Date
WE REQUIRE A 2 WEEK NOTICE PRIOR TO YOUR RETURN TO YOUR POSITION.

YOUR REQUEST WILL BE FORWARDED TO MELANIE SHANLEY, DIRECTOR OF HR

(melanie@arcus.email)
YOUR EMPLOYEE BENEFITS, AS PER THE UNION CONTRACT, WILL BE DISCONTINUED ON:

MonthDayYear
Date
Authorized by:

First NameLast Name
Date:

MonthDayYear
Date
Phone Number
Please enter a valid phone number.
Should be Empty:

CHANGE OF STATUS REQUEST