Fire Service Recovery Leave of Absence Form
Submit your request for a recovery-related leave of absence. Please complete all sections for processing.
Full Name
*
First Name
Last Name
Employee/Service ID
*
Department/Station
*
Position/Rank
*
Contact Email
*
example@example.com
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
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
Type of Recovery Leave
*
Medical (Illness/Surgery)
Injury (On Duty)
Injury (Off Duty)
Other
Reason/Details for Leave
*
Supervisor Name
*
Supervisor Contact Email
*
example@example.com
Signature (Applicant)
*
Submit Leave Request
Submit Leave Request
Should be Empty: