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Employee Leave Request Form

Rudolph Kolder submitted an employee leave authorization form requesting paid time off hours for sick leave. The form notes that accrued PTO must be exhausted first before using sick bank hours. Kolder works at LaPalmaCC and listed no dates for the requested leave. By signing, Kolder authorized CoreCivic to deduct from final pay any advanced hours not used if employment terminates. The supervisor and time clock operator must also sign to approve or deny the request.

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Rudolph Kolder
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104 views1 page

Employee Leave Request Form

Rudolph Kolder submitted an employee leave authorization form requesting paid time off hours for sick leave. The form notes that accrued PTO must be exhausted first before using sick bank hours. Kolder works at LaPalmaCC and listed no dates for the requested leave. By signing, Kolder authorized CoreCivic to deduct from final pay any advanced hours not used if employment terminates. The supervisor and time clock operator must also sign to approve or deny the request.

Uploaded by

Rudolph Kolder
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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EMPLOYEE LEAVE AUTHORIZATION 3-5-2A

Employee’s Name: Kolder, Rudolph Emp. #: 14780351

Work Location: LaPalmaCC Date Submitted:


Please enter the amount of paid hours needed and the type of leave requested in the appropriate box.
PTO Hours: Sick Bank Hours: Bereavement Hours:
(Accrued PTO must be exhausted first)
Holiday Hours: What Holiday?
FMLA Leave (please check applicable reason): Personal Illness*? Family Illness*? Parental?
Military Leave** Hours: Civil Leave** Hours:
* For FMLA, a Certification of Health Care Provider is required and should be submitted with this form.
** Military and Civil Leave will require written documentation of absence.
Please list the dates on which these hours were taken:

In the event that my employment terminates for any reason, by my signature below, I authorize CoreCivic to deduct from my final pay a monetary amount equivalent
to any pay advance for the above hours not offset, in accordance with applicable federal and state law.

Employee’s Signature: Date:

Supervisor’s Signature: Date:

Entered into time clock by: Date:


Approved: Denied:

04/24/2017

________________________________________________________________________________________

EMPLOYEE LEAVE AUTHORIZATION 3-5-2A


Employee’s Name: Kolder, Rudolph Emp. #: 14780351

Work Location: LaPalmaCC Date Submitted:


Please enter the amount of paid hours needed and the type of leave requested in the appropriate box.
PTO Hours: Sick Bank Hours: Bereavement Hours:
(Accrued PTO must be exhausted first)
Holiday Hours: What Holiday?
FMLA Leave (please check applicable reason): Personal Illness*? Family Illness*? Parental?
Military Leave** Hours: Civil Leave** Hours:
* For FMLA, a Certification of Health Care Provider is required and should be submitted with this form.
** Military and Civil Leave will require written documentation of absence.
Please list the dates on which these hours were taken:

In the event that my employment terminates for any reason, by my signature below, I authorize CoreCivic to deduct from my final pay a monetary amount equivalent
to any pay advance for the above hours not offset, in accordance with applicable federal and state law.

Employee’s Signature: Date:

Supervisor’s Signature: Date:

Entered into time clock by: Date:


Approved: Denied:

04/24/2017

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