CERTIFICATED REQUEST FOR LEAVE OF ABSENCE WITHOUT PAY

CERTIFICATED REQUEST FOR LEAVE OF ABSENCE WITHOUT PAY
School Year *
Name*
Employee ID*
Phone*
MDUSD Email*
example@example.com
Address*
School Site*
Current Supervisor Email*
example@example.com
Confirmation of Supervisor Email*
example@example.com
Grade Level/Subject Assignment*
I hereby request a leave of absence without compensation from active service under the conditions as indicated below (check one):*

Improvement of HealthOpportunityPoliticalEducational ImprovementMaternityPre-retirementGeneralParental
Do you have a medical note?*

YesNo
Please Upload Medical Verification*

Cancelof
Duration of Leave:
Last date of service*

MonthDayYear
Date
Requested Date of Return To Service (Must be working day)*

MonthDayYear
Date
Please give information to clarify above*
It is understood that this is an unpaid Leave of Absence. The employee does not receive compensation. I have read the Contract Provision related to this unpaid leave and understand its provisions.
Date*

MonthDayYear
Date
Signature*

Clear
Note:
- If you wish continuation of benefits at your expense while on leave, you must contact the Benefits Department prior to the first day of your leave to make these arrangements.
- Email access will be suspended while on leave. Please contact HR one week prior to return to reinstate access.
Should be Empty: