City of Alexandria

City of Alexandria

Leave Request Form

Date: ______

Employee’s Name: ______

Job Title: ______Social Security No.:______

Department: ______Division:______

Reason For Leave:

( ) Adoption of a Child( ) Personal Disability / Illness

( ) Annual Leave( ) Illness of a Child

( ) Birth of a Child( ) Illness of Spouse

( ) Civil Leave( ) Illness of Parent

( ) Compensatory Time Off( ) Family Death (relationship): ______

( ) Military ( ) Training

( ) Administrative Leave( ) Other (explain): ______

______

Length of Leave:

From:Date: ______Time: ______( ) a.m. ( ) p.m. Total Hours: ______

To:Date: ______Time: ______( ) a.m. ( ) p.m.Total Days: ______

Note: Complete Time Section if less than a full day of leave is being requested.

Employee’s Signature: ______Date: ______

------Department Use Only------

Type of Leave Approved: Leaves in this section require only the department head’s approval. Starred leaves require a copy of this form and paperwork be submitted with payroll.

( ) Annual Leave (VA)( ) Sick Leave (SL)

( ) Compensatory Time (CT)( ) Civil Leave (CL) *

( ) Funeral Leave (FL) *( ) Approved Leave Without Pay (AP)

( ) Leave Not Approved (NP) (Explain): ______

Approved By: ______Date: ______

Department Head or Designee

Type of Leave Approved: Leaves in this section require approval at all levels. A copy of this form must be submitted to the Civil Service / Personnel Office with required documentation.

( ) Military Leave (ML)( ) 60-Days Other Leave Without Pay (OL)

( ) Family Medical Leave Without Pay (OL)( ) Administrative Approved Leave (AL)

Approved By:

______

Department Head or DesigneeDate

______

Division Head or DesigneeDate

______

Mayor Date

______

Director of Personnel or DesigneeDate

Revised 04/05