Military Leave Request Form
MILITARY LEAVE REQUEST FORM
Please Print, Type or Write Legibly
Check one: New Leave of Absence: Revision of original request (superseding): Extension of Leave:
Department Name: ___________________________ College/Division: ________________________________________
Employee ID #:______________ Position Title: ___________________________ Check one: USPS: A&P: Faculty:
Employee’s Name: _________________________________________________________________________________________
Last name First name Middle Initial
Home Mailing Address: ____________________________________________________________________________________
Street Address/P.O. Box City State Zip
Home Email Address: _________________________________ Campus Email Address: _______________________________
Campus Phone #: __________________ Home Phone #: ____________________ Cell Phone#:________________________
Reason for Leave: Active Duty Military Leave Military Training (active or inactive duty)
A copy of your military order(s) must be submitted no later than 30 days after the start of this leave.
Last Day of Work: _________________ Leave Start Date: _________________ Leave End Date: _________________
While on military leave I will use: (check all that apply)
□
Military Training Leave
(May use up to 240 hours Admin. leave for Active or Inactive Duty for Training)
From_______to ______
□
Military Leave with pay
(First 30 calendar days of Admin. leave for Active Duty not for Training per order No.)
From_______to______
□
Military Leave with pay
(After first 30 days of Active Duty)
From_______to______
□
While on leave with pay I will use □ Annual Leave □ Compensatory Leave □
Military Pay Supplement
□
I wish to use a minimal amount of accrued leave to maintain my insurance benefits.
□ Military Leave without pay
(After using maximum Admin leave for training or active duty)
From_______to______
□
Military Personal Leave
(Based on time limits for returning from Active Duty)
From_______to______
While on personal leave I will use □ Annual Leave □ Compensatory Leave □ Leave without Pay
While on active military duty my military pay will be lower than my UCF salary. After receiving full pay for 30 days, I
understand that I am eligible for a military pay supplement and must provide a copy of my Military Leave and Earnings
Statement for my first 30 days of active military service. ________Initials
I anticipate returning to my normal work schedule and duties on: Date: ____________________ Time: ______________
I understand and accept a leave of absence as stated on this page. I further acknowledge that I have read the “Employee and Department Responsibilities for
Completion” page accompanying this form and I
understand
all of my leave responsibilities and the information provided therein:
Employee Signature: ______________________________________ Date: _____________________________________
For Use By Department and Human Resources
Department (Supervisor) must complete (Please type or print legibly):
Payroll Processor: ________________________________________________________email:_______________________________________________________
EPaf Processor: __________________________________________________________email:_______________________________________________________
HR Liaison: _____________________________________________________________email:_______________________________________________________
Approved
Yes: No: Signature Chair/Supervisor: ________________________________________________________ Date: ______________________________
Print Full Name: ______________________________________________________ Campus Extension: ______________________________
Email Address: _______________________________________________________________________________________________________
Yes: No: Signature Dean/Director: __________________________________________________________ Date: _______________________________
Print Full Name: _____________________________________________________ Campus Extension: ______________________________
Email Address: _______________________________________________________________________________________________________
Comments:_____________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
For HR Use Only
The Human Resources Director has Final Approval for all military leaves of absence.
This request for leave of absence is approved: YES: NO: Employee is on paid leave: Employee is on unpaid leave:
Human Resources Director: By: _______________________________________________________ Date: ________________________________________________
Comments: _____________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
Revised Dec 2013
Page 1/2
Free Download
Military Leave Request Form PDF
Favor this template? Just fancy it by voting!
(0 Votes)
0.0
Related Forms
1 Page(s) | 1219 Views | 26 Downloads
