Leave of Absence Unpaid: Department Head Recommendation and Dean/Vice President Request to the Provost (Appointed Personnel - Faculty, Administrative, and Professional)

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Date To Be Issued
Employee's Name (Do not address to Human Resources or Employee File)
Employee's Title:
Recommended by: Dept Head/Director:
Requested by: Dean/Vice President:
Must be signed by Dean/V.P.
Briefly state reason for Leave of Absence request.
Do you want to ask for approval or denial of this request?
Briefly state reason for approval or denial of Leave of Absence request.
Leave of Absence start date:
(date after last day of work)
Leave of Absence end date:
(leave cannot exceed one year)
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August 3, 2005