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Get Request For Leave Of Absence And Extension Of Leave Form

Ame: Phone: I have read and understand the directions and general conditions of taking a leave. If my request is approved, I agree to comply with all requirements. Further, I will contact the Benefits Office, 275-2084, regarding continuation of benefits. Date: Employee Signature: Supervisor/Department Head Completion Please confirm that the employee meets the following eligibility requirements: Does the employee have two (2) years or more of service? Yes No If the employee previously had.

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