Rev. 8/28/2015
REQUEST FOR LEAVE AND OVERTIME F3.6A
FACULTY AND STAFF
Name: ________________________________________________
Application is hereby made for approval of leave for the following reason(s) and period(s).
DATE(S) TOTAL HOURS
Vacation
Sick (1)
Self Family
Overtime taken
State
FLSA
Overtime earned
State
FLSA
Bereavement (3)
Emergency (3)
Military
Maternity
Jury Duty (attach jury summons)
Leave Without Pay
1. Sick: Nature of illness ________________________________________________________
2. Bereavement:
The death of my __________________ ______________________ occurred ___________
(Relationship) (Name) (Date)
3. Nature of emergency leave requested: __________________________________________
4. Additional Comments: _______________________________________________________
I hereby certify that the above information is true and correct.
____________________________ ______________________________
Employee Signature Supervisor’s Signature
_______________ Approved ______________
Date Disapproved Date
