Employee request for an unpaid or partially paid personal leave of absence for non-FMLA qualifying reasons. Covers leave purpose, dates, pay/benefit arrangements, and return-to-work commitments.
The Personal Leave of Absence Request is a ready-to-use employment & hr template you can send for signature in minutes. It is written for 1 signer (employee) and, by default, expires 30 days after it is sent if left unsigned. It covers personal leave, leave of absence, loa, unpaid leave, leave request, hr. Like every Abundera Sign template it is a convenience draft structured for ESIGN Act and UETA compliance, not a substitute for legal advice. Each signed copy is sealed with PAdES-LTA digital signatures, dual RFC 3161 timestamps, and a tamper-evident evidence package in WORM storage.
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# Personal Leave of Absence Request This form documents an employee's request for a personal leave of absence that does not otherwise qualify under FMLA, state statutory leave, or another company-specific leave program. Approval is at the discretion of the employer unless otherwise required by law. --- ## Part A — Employee Information **Full Legal Name:** ___________ **Employee ID / Personnel Number:** ___________ **Department:** ___________ **Job Title:** ___________ **Manager / Supervisor Name:** ___________ **Work Email:** ___________ **Work Phone:** ___________ **Date of Hire:** ___________ **State of Employment:** ___________ --- ## Part B — Reason for Leave **General Category of Reason for Personal Leave:** ___________ **Brief Description of Reason (provide only what you are comfortable sharing; detailed medical information is not required for this form):** ___________ **Has this reason been reviewed by HR for applicability of a specific statutory leave program (e.g., FMLA, ADA, state leave)?**