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. Falsication 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 dened 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-
GBCC
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