Mining Industry Vacation Leave of Absence Form
Submit your request for vacation or leave of absence. Please complete all required fields to ensure timely processing.
Employee Full Name
*
First Name
Last Name
Employee ID Number
*
Department
*
Please Select
Operations
Maintenance
Safety
Administration
Logistics
Other
Job Title
*
Work Email Address
*
example@example.com
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Type of Leave Requested
*
Annual Vacation
Medical Leave
Personal Leave
Unpaid Leave
Other
Leave Start Date
*
-
Month
-
Day
Year
Date
Leave End Date
*
-
Month
-
Day
Year
Date
Total Number of Leave Days Requested
*
Reason for Leave
*
Supervisor/Manager Name
*
Emergency Contact Name
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Employee Signature
*
Submit Leave Request
Submit Leave Request
Should be Empty: