Apply for v Non-Paid Leave Of Absence Request -Internal Use Only

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Summary
Title:	v Non-Paid Leave Of Absence Request -Internal Use Only
ID:	1017
Department:	Human Resources
Contact Information
* First Name:
* Middle Name:
* Last Name:
* Address 1:
Address 2:
* City:
* State:
* Zip:
* Phone:
* Email:

Albert USA Non-Paid Leave Of Absence Request

*At this time according to Federal Law, Albert Mfg USA is not required to grant leaves under the FMLA policy. We do not have 50 or more employees. Please refer to handbook for more details.

* Start Date:

* Expected Return Date:

* Explanation of why you require a Non-Paid Leave of Absence:

Leaves of absence are non-paid. If you would like to use any Vacation Time or Sick Time you have available, you must complete a separate Time Off Request Form for it.

* Is this a request for an extension of a current Non-Paid Leave of Absence you are unable to return from?

Yes No

If this is a request for an extension, please list the dates from your original Non-Paid Leave of Absence.

Original From:

Original To:

Conditions for Non-Medical Unpaid Extended Leave of Absence
• Your current position may be eliminated during the requested term of absence.
• The vacancy created by your absence may be filled by another employee.
• If your current position is eliminated or filled by another employee, you may be considered for other comparable positions within this company.
• If no comparable position is or becomes available at the expiration of this leave of absence, the company may terminate employment relationship.

Eligibility
• Full-time regular employees on Albert Mfg payroll are eligible for Non-Paid Extended Leave.
• Employees become eligible to request Non-Paid Extended Leave on the completion of their first 90 days of service with Albert Manufacturing USA.
• Employees may be placed on unrequested Non-Paid Leave of Absence by Upper Management of Albert Manufacturing USA when necessary with an undetermined return date.

Non-Paid Leave Guidelines
• Employee submits a request with documentation of reason to Upper Management for Non-Paid Extended Leave approval.
• Request must be submitted at least 2 weeks before desired extended leave date when possible.
• Upper Management will review business needs to determine if request can be approved.
• If granted the employee must return back to work on the day the Non-Paid Extended Leave has ended. If the employee does not return to work, and does not call in to Human Resource, time after the return to
work date will be considered unexcused.
• The continuance of a Non-Paid Extended Leave must go through the same approval process as the original leave before they were originally supposed to return to work. Failure to do this will cause days missed to
fall under attendance policy rules.

Non-Paid Leaves will have the following limitations:
• Extended leaves are limited to a total of 2 approved leaves per 12-month period.
• Extended leaves are limited to a total of 8 weeks maximum per 12-month period.
• Extended leaves will be granted for a minimum of 3 full weeks (15 business days) only.
• Daily leaves will be limited to a total of 1 request form per 6 months (Jan – June & July – December).

Daily Non-Paid Leave for Appointments in the future:
If you have ongoing appointments for Medical reasons in the future for a limited amount of time, please list here:

Date:

Time you will leave & return:

Date:

Time you will leave & return:

Date:

Time you will leave & return:

Date:

Time you will leave & return:

Date:

Time you will leave & return:

Please type your First and Last name as an electronic signature to acknowledge that this request is only intended for current employees and you confirm that are the employee and you completed this form by yourself with true and accurate information..

President Approval: Yes  No 

_____________________________________________________________________________________________

I agree that this form may be electronically signed and agree that my typed signature is the same as a handwritten signature for the purposes of validity, enforceability, and admissibility.

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