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.
Should be Empty: