HR - Leave of Absence Request Form
Full Name
*
First Name
Last Name
DM and Store #
*
Position
*
Please Select
Insider
Driver
Shift Lead
Team Lead
GMIT-1
GMIT-N1
GMIT-2
GMIT-N2
GMIT-3
GMIT-N3
AM
GM
Last 4 of Social #
*
TM Email
*
example@example.com
Leave Start Date
*
-
Month
-
Day
Year
Date
Leave End Date
*
-
Month
-
Day
Year
Date
Leave Type
FMLA (Select Reason)
Please Select
Medical
Birth/Adoption of a Child
Care for Spouse/Child
Military
Eligibility Requirement: 1 year of service
PERSONAL LEAVE (Select Reason)
Please Select
Medical
Birth/Adoption of a Child
Care for Spouse/Child
School
Personal
Attach Backup Documents
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Approved by DM
YES
NO
DM Name
Please Select
Andrew Pogue
Anthony Destephano
Dane Leonard
Gabe Nall
James Farr
Jason Holt
Maria Shoaf
Mario TorresTrujillo
Mark Tackett
Nate Dersch
Nick Reidel
Niki Clemons
Peter Schwinger
Ryan Martinez
Scott Kuhn
Shruti Patel
Silver Idrogo
Steven Burk
District Manager Sign and Date
*
DO Name
Please Select
Erick Ortiz
Jeff Allison
Pat VanDierendonk
Director of Operations Sign and Date
HR EMAIL
Please Select
Sherri.seidel@teammurph.net
Back
Next
Save
DM Email
example@example.com
DO Email
example@example.com
HR Email
example@example.com
Should be Empty: