FILE: GBRI-E
REQUEST FOR LEAVE OF ABSENCE
WASHINGTON PARISH SCHOOL BOARD
POST OFFICE BOX 587
FRANKLINTON, LOUISIANA 70438
Applicant's Name Date of Birth ______________________
Present Mailing Address ______________________________________
Street or Route Number
_________________________________________________________
City State Zip Code
Job Location Position ____________________________
Type of Leave Requested (check one)
Sick Military Leave Without Pay
State Reason(s) _____________________________________________
Effective Date of Leave Requested _______________________________
Length of Leave _____________________________________________
Date & type of last leave from Washington Parish School Board
__________________________________________________________
If leave is requested for illness, attach physician's statement verifying necessity of leave.
I hereby certify that the above information is true and correct to the best of my knowledge.
_____________________________________________________________________
Signature of Employee Date
* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *
TO BE COMPLETED BY SCHOOL BOARD OFFICE
Type of Leave Date Requested ___________________________
Action of School Board Approved Salary on Leave ________________
Denied Date of Application ______________
Date of Board Action ____________________
___________________________________________________________________
Signature of Superintendent Date
Washington Parish School Board