This Form Must Be Returned to Human Resources Within 7 Days

EXHIBIT 4

LEAVE OF ABSENCE AGREEMENT

This form must be returned to Human Resources within 7 days,

either before going on leave or within 7 days of starting leave.

THIS LEAVE IS REQUESTED FOR THE PURPOSE OF (check one):

Name:______Dept.: ______

Position: ______Hire Date: ______

Home Address: ______Home Phone:______

______

I hereby apply for a leave of absence for ______days from ______through ______

The reason for the leave is as follows: ______

______In the event the leave is granted, I understand and agree that:

1. I will accrue no vacation or sick leave during the Leave of Absence period; however, I will suffer no loss of creditable service for purposes of PTO leave, retirement, and length of service awards.
2. A leave for medical reasons must be accompanied by a doctor’s certificate stating physician’s diagnosis, brief statement of treatment, the estimated length of disability, and a statement that the employee is unable to perform basic functions of the position. A written clearance from the doctor must be presented to the Human Resources office prior to my return to work. I understand that during my leave “timely” medical certifications may be requested from my health care provider.
3. Depending on the reason for the Leave of Absence, I am required to use my accrued sick and/or PTO leave for salary continuation during this period.
4. My return to work will be subject to employment conditions existing at the time of my return. We will attempt to keep the same or similar position available for the approved leave period depending on the reason for the Leave of Absence, provided it does not create an undue hardship for the Company. I must notify my supervisor at least two weeks prior to the above stated ending of the Leave of Absence to confirm the date of my return to work. I further understand that my same or similar position will not be kept available beyond the stated leave of absence period unless superseded by federal, state, or local laws. I understand that if I do not return to work by the above indicated date, I will have voluntarily resigned my position with the Company.
5. If I am unable to return by the above date, I must notify the Human Resources office and theDepartment Head in writing at least 5 days before the expiration date to request an extension. This request must state the need for the extension, length of time required, and be supported by a doctor’s statement in the event the leave is for medical reasons. Failure to return or obtain an approved extension will result in termination of employment. If I fail to return from leave for reasons other than a serious health condition or other circumstances beyond my control, I agree that I will reimburse the Company for health care contributions, if any, made on my behalf.
6. Accepting other employment while on leave of absence will result in the termination of my employment with the Company.
7. I understand that my leave of absence begins on the first missed day of employment, regardless of when my leave of absence was requested and/or approved.

Employee SignatureDateHuman Resources

Revised 7-2008

Revised 7-2008