BOARD POLICY
#4021A
June 11, 2008
APPLICATION FOR LEAVE UNDER THE
FAMILY MILITARY LEAVE ACT
EMPLOYEE ______________________ POSITION ______________________
LEAVE REQUESTED: I request to take a family military leave.
Start Date: _________________ End Date: _________________
SPOUSE OR CHILD DEPLOYED: _______________________________ [Insert Full Name] is: ____ My Spouse ____ My Child (Check One) and has been called to military service lasting 179 days or longer with the state or United States pursuant to the orders of the _____ Governor or the _____President of the United States. The dates the deployment orders are in effect are: ____________________ (Start Date) ___________________ (End Date).
CERTIFICATION: I certify that the above information is correct. I understand that the family military leave is unpaid. I understand that my benefits will be continued. I will be responsible for my share of health or other insurance premiums. I will on request submit certification from the proper military authority to verify eligibility for the family medical leave.
DATED this ____ day of _______________________, 200_.
SIGNED BY:
Employee
ACTION ON FAMILY MILITARY LEAVE REQUEST
Your leave request is:
_____ Granted
_____ Pending. Will be acted on after you submit certification from the proper military authority to verify the deployment orders.
______ Denied for the reason(s) that:
_____ You failed to give the required advance notice.
_____ The requested leave schedule would unduly disrupt operations of the school. Please contact me to consult about alternative scheduling.
_____ You are not eligible for family military leave.
Comments: ___________________________________________________________.
DATED this ____ day of _____________________, 200__.
BY: ________________________
Superintendent
