Request for Leave of Absence
Arcanum Police Department
Date
*
/
Month
/
Day
Year
Date
Name
*
First Name
Last Name
Work Email
*
example@example.com
Leave Requested
*
Sick
Funeral
Vacation
Jury Duty
Military Leave
Military, Long-Term
Personal Leave
Unpaid Leave
Reason for Leave:
*
Beginning Date/Time of Leave:
*
/
Month
/
Day
Year
Date
Hour Minutes
Ending Date/Time of Leave:
*
/
Month
/
Day
Year
Date
Hour Minutes
Total Hours of Leave:
*
SICK LEAVE ONLY (Give details of reason for sick leave usage):
Medical/Dental/Optical appointment of employee
Illness of employee
Injury of employee
Medical appointment of family member
Illness of injury of family member
Death of family member
Give further details of sick leave
Date of Death:
-
Month
-
Day
Year
Date
Date of Funeral
-
Month
-
Day
Year
Date
I certify all statements herein to be complete and true. Falsification is cause for discipline up to and including termination of employment.
*
File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Preview PDF
Submit
Should be Empty: