Northwestern Connecticut Community College
Leave Request Form
Name: ___________________________________ Date:_________________
I am requesting leave for the following date(s)
From:_________________ To: ___________________
Days/Hours;____________________________________________
This leave should be charged to:
Vacation
Personal Leave * Holiday Sick Jury Duty
Approved: _____________ Not Approved:________________
Supervisor:________________________________________ Date:________________
Please submit leave form one week in advance if possible.
CC: Appropriate Dean
* Faculty must complete Personal Leave Request Form with the Dean of Academic Affairs