REQUEST FOR LEAVE OF ABSENCE
Non-FMLA Leaves

Date: 	

Employee's Name:  	_

Department: 	_

First day of requested absence: 	_

Date of expected return:

Reason for leave:

It is understood that leaves of absence and extensions are at the discretion of the company and that reinstatement is subject to the staffing needs of the company at the time reinstatement is requested.
Employee's Signature: 	       Date: 	_ Supervisor's Signature: 	  _   Date: 	_

Manager's Signature: 	

Date: 	

Human Resource Manager's Signature: 	

Date:. 	

Doctor's note attached (A doctor's note must be attached to any medical leave of absence request before approval may be given.)

Northeastern Retail Lumber Association 12-11