Pharmacy Personal Leave of Absence Request
Submit your personal leave request for review and approval by pharmacy management.
Employee Full Name
*
First Name
Last Name
Position/Job Title
*
Department/Pharmacy Location
*
Employee Email Address
*
example@example.com
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Type of Leave Requested
*
Personal Leave
Medical Leave
Vacation
Other
Leave Start Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Leave End Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for Leave
*
Who will cover your responsibilities during your absence? (Name and contact, if applicable)
Supervisor/Manager Name
*
Additional Comments or Special Instructions
Employee Signature (Please sign below)
*
Submit Leave Request
Submit Leave Request
Should be Empty: