APPENDIX F

   VILLAGE OF ORLAND HILLS UNPAID LEAVE OF ABSENCE FORM

Date:    

Employee:    

Department:   

Type of Leave: (check one)                            Extended Illness

                                           Maternity Leave

                                           Emergency Leave

                                           Military Leave

                                           Other

Number of Days Expected to be taken:   (Maximum 6 months)                  

Expected Return Date:   

Will you continue Health Insurance Enrollment for yourself?    

                            family    

         (employee must pay all premiums during leave)

Employee Signature:   

Supervisor Approval   

Supervisor Denial   

Extension Request:

   *Number of Days Expected to be taken: (Maximum 6 month

      Employee Signature:    

      Supervisor Approval:   

      Supervisor Denial:   

*Please submit medical certificates and all other documents that may be required by ordinance or by your Supervisor.

Copies:   Finance

      Department

      Employee

(Ord. 89-09, passed 4-12-89)