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)