Leave of Absence Request Form

Name: *

Restaurant: *

Position: *

Date Employment Began: * +

Your email address: *

Please let us know your current address and phone number. *

Why are you requesting a leave of absence? *

What is the requested start date for your leave of absence? * +

What is the end date of your requested leave of absence? * +

Do you have insurance through us? *

Insurance: If yes, please let us know how you would like to pay your portion of insurance while you are on leave. If no, please type in n/a. *

Thank you for submitting this request. Once your request has been reviewed, if further information is needed for a decision to be made, you will be contacted promptly. Once a decision has been made, you will receive a response via email or through your General Manager.