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VILLAGE OF ORLAND HILLS UNPAID LEAVE OF ABSENCE FORM
Type of Leave: (check one) Extended Illness
Number of Days Expected to be taken: (Maximum 6 months)
Expected Return Date:
Will you continue Health Insurance Enrollment for yourself?
(employee must pay all premiums during leave)
*Number of Days Expected to be taken: (Maximum 6 month
*Please submit medical certificates and all other documents that may be required by ordinance or by your Supervisor.
(Ord. 89-09, passed 4-12-89)