ALBANY STATE UNIVERSITY
A Unit of the University System of Georgia
ALBANY, GEORGIA
APPLICATION FOR PERSONAL LEAVE OF ABSENCE
Date: , 20____
EMPLOYEE NAME:
(Print)
DEPARTMENT:
It is requested that Leave of Absence (as indicated below) for hours, from _____
a. m. ( ) / p.m. ( ) through a.m. ( ) / p.m. ( ) be granted to the undersigned, on the
following date(s) .
Employee Signature:
Absence Codes (Please check appropriate code)
1. ( ) Vacation Leave With Pay
2. ( ) Vacation Leave Without Pay
3. ( ) Sick Leave With Pay (Employee or Immediate Family)
Approved sick leave is granted due to an employee=
==
=s
illness and illness or death of an immediate family member.
Immediate family is defined to include father (father-in-law),
mother (mother-in-law), brother, sister, husband, wife and
children (step, adopted or foster).
4. ( ) Sick Leave Without Pay
5. ( ) Vacation Leave With Pay (Worker=s Compensation)
6. ( ) Sick Leave With Pay (Worker=s Compensation)
7. ( ) Sick Leave Without Pay (Worker=s Compensation)
8. ( ) Military Leave With Pay
9. ( ) Military Leave Without Pay
10. ( ) Jury Duty (Attach Summons)
11. ( ) Other (Please Explain)
Administrative Approval
Supervisor Date
DO NOT WRITE IN THIS SPACE
(For action of Leave Clerk)
Reason (if denied)
Signature: Date Posted:
Application for Leave of Absence MUST be made for EVERY period of absence from work BEFORE taking any leave,
except in case of illness or EMERGENCY.
Please submit in duplicate
Form No. ASUFA 400
Effective Date 01/03/00
