REV 10/12
Name (Please Print) _____________________________________________________________
Employee ID or SSN (Enter only last 4 digits of SSN) ________________________________
CCSNH Institution: ______________________________________________________________
APPLICATION
FOR LEAVE
TYPE OF BEGINNING ENDING TOTAL
LEAVE DATE TIME DATE TIME HOURS
_____ ____________ ____________ ____
_____ ____________ ____________ ____
_____ ____________ ____________ ____
TYPE OF LEAVE: ADMN - Administrative Leave
VAC - Annual Leave
FYPD - FY Personal Day
BNSL - Bonus Leave
CIVL - Jury Duty/Civil Leave*
CMPT - Compensatory Time
MLTR - Military Leave*
LWOP - Leave Without Pay
FMLA - Family & Medical Leave*
SICB - Sick Bereavement
SICD - Sick Dependent
SICE - Sick Employee
SICP - Sick Personal Leave
RESPONSE TO EMPLOYEE REQUESTING LEAVE:
r Recommended
r Not Recommended
r Approved
r Not Approved
r Unauthorized
Immediate Supervisor Date
Administrator Authorized to Approve Leave Date
Certification: I hereby request leave/approved absence from duty as indicated above and
certify that such leave/absence is requested for the purpose(s) indicated. I understand that
I must comply with the procedures for requesting and utilizing leave, and provide supporting
documentation, if required. Falsication of this Application for Leave or supporting documentation
may be grounds for disciplinary action, up to and including dismissal.
Sick Leave: Please indicate the reason for the sick leave request below.
[ ] Personal illness or injury
[ ] Serious health condition as dened by the FMLA
[ ] Dependent Care
[ ] Medical/Dental appointment
[ ] Bereavement Leave
[ ] Personal Leave
[ ] Donation of Sick Leave to: _______________________________________________
Print Name of Employee to Receive Sick Leave
Reason for Non-Approval:
Employee Signature: Date:
(*Requires appropriate documentation)
xxx-xx-
