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Application for Leave 1
Application for Leave 1
ROP MOA-BPSS-05 APPLICATION FOR LEAVE
INSTRUCTIONS Please complete items 1-8
1. Name: (Print or type - Last, First, M.I.) 2. Employee Social Security Number
3. Organizational Unit 4-A Month Day Hour A.M. 4-C
Total Numbe
r
of Hour
s
FROM: P.M.
5. I hereby request
(If more than one box is cheched, explain
4-B Month Day Hour A.M.
in item 6, Remarks):
Annual Leave.
Sick Leave
TO: P.M.
Leave Without Pay. 6. Remarks
Administrative Leave.
Maternity Leave.
Other. (Specify)
7. Employee-s Signature
8. Date
(Month, Day, Year)
Approved
Disapproved (If disapproved, give reason
Signature
Date (Month, Day, Year)
If annual leave, initiate actio
n
to reschedule.
)
Any and all leave must be requested in advance using this form. For sick leave requested lasting over three working days,
attach a doctor's certificate to this application and submit for approval. Supervisors may also require a doctor's certificate
if use of sick leave is chronic and excessive. All employees are encouraged to read the Public Service System Rules and
Regulations and in particular the regulations regarding leave.
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OFFICIAL ACTION ON APPLICATION
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