APPLICATION FOR LEAVE                                                                                  
                Employee Information: 
                   Agency/Department:                                                                                        Employee Name:           
                    
                   Number of Hours of Leave Requested:                                                                       From Date:                                                        To Date:            
                                                                                                                             Time:                                AM           PM              Time:                             AM            PM 
                Leave Information: 
                                               Chargeable Leave                                                                                                   Non-Chargeable Leave 
                        Annual Leave                      Sick Leave                  LWOP                           Military                     Civil:                                           Special: 
                   If FMLA, select one of the following:                                                             Job Related                        Jury Duty                                        Funeral 
                                          Self              Military Caregiver                                  Education                               Witness Subpoena                                 Office Closure 
                                          Family             Qualifying Exigency                                      Other (explain                    Emergency Civilian                               Job Related Exam 
                                                                                                                in comments)                            Voting 
                   Comments: 
                              
                   If Part-Time, list number of hours worked each day. 
                                       Sunday               Monday               Tuesday               Wednesday               Thursday               Friday               Saturday 
                Employee Certification: I CERTIFY THAT MY ABSENCE FROM DUTY WAS FOR THE REASON NOTED ABOVE. 
                   Employee Signature:                                                                                                                                                Date: 
                    
                Approval: 
                   Supervisor Signature:                                                                                                                                                  Date: 
                    
                Leave Definitions: 
                   CHARGEABLE LEAVE: leave taken which reduces                                     Qualifying Exigency: may arise when a spouse, son,                                       4.      Funeral: Leave granted when 
                   accrued leave balances.                                                         daughter or parent who is a member of the Armed                                                  attending the funeral or burial rites of 
                           1.      Annual: Leave with pay granted an                               Forces (including the National Guard and Reserves)                                               a parent, step-parent, child, step-child, 
                                   employee for the purpose of                                     and who is on covered active duty or has been                                                    brother, step-brother, sister, step-
                                   rehabilitation, restoration and                                 notified of an impending call or order to covered                                                sister, spouse, mother-in-law, father-
                                   maintenance of work efficiency, or                              active duty.                                                                                     in-law, grandparent or grand-child; 
                                   transaction of personal affairs.                                NON-CHARGEABLE LEAVE: leave taken which does                                                     provided such time off shall not exceed 
                           2.      Sick: Leave with pay granted an                                 not reduce accrued leave balances                                                                two days on any occasion. 
                                   employee who is suffering with a                                        1.      Military: leave granted when called to                                   5.      Office Closure: Chancellor determines 
                                   disability which prevents him from                                              active military duty; annual training or                                         that because of local conditions it 
                                   performing his usual duties and                                                 active duty for training (weekend drills);                                       would be impossible or impracticable 
                                   responsibilities or who requires medical,                                       to conduct mandatory physical to enlist in                                       for the employee to report to work. 
                                   dental or optical consultation or                                               military.                                                                6.      Job Related Exam: leave granted to 
                                   treatment.                                                              2.      Job Related Education: leave granted to                                          participate in a State Civil Service Exam 
                           3.      LWOP: Leave without Pay                                                         attend a course that is relevant to job and                                      or to take other exams pertinent to the 
                                                                                                                   approved per provisions of PM 12.                                                employee’s position. 
                   FMLA: (Family Medical Leave Act) approved                                               3.      Civil Leave: leave granted to:                                           7.      Other: Any other special or non-
                   absence available to eligible employees for up to 12                                                    a.      perform jury duty                                                chargeable leave request as provided 
                   weeks of leave per year for certain family medical                                                      b.     appear as subpoenaed before                                       in Chapter 11 of the C.S. Rules 
                   reasons.                                                                                                       a court, public body, or 
                   Self: For employee’s own serious health condition.                                                             commission 
                   Family: An immediate family member (spouse,                                                             c.     perform civil duties in 
                   child, or parent) with a serious health condition.                                                             connection with national 
                   Unpaid: When paid leave (annual/sick) is exhausted                                                             defense or other civil 
                   or cannot be used under specific circumstances.                                                                emergencies 
                   Military Caregiver: leave granted to care for a                                                         d.     vote 
                   family member who is a covered veteran with a 
                   “serious injury or illness”.