Office of Employee Services
Leave Without Pay Request Form
Name:
Department: -SelectDate:
Employee ID:
Dates Requested
Number of Hours
Purpose of Leave: (Clearly present the purpose of the leave per NDUS HR Policy 21 Leave Without Pay)
Employee Signature:
Date:
Supervisor Signature:
Date:
Submit to: Employee Services
McFarland 211
(701)845-7401
Request Approved: Yes
No
HR Director or Other Authorized Officer Signature:
101 College Street SW ♦ Valley City, ND 58072 ♦ 701 845 7401 ♦ fax 701 845 7247 ♦ [email protected]