Farmworker Leave of Absence Form
Use this form to formally request time away from work. Please complete all sections accurately for timely review.
Full Name
*
First Name
Last Name
Job Title or Role
*
Primary Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Supervisor or Manager Name
*
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 Leave
*
Please Select
Sick Leave
Personal Leave
Family/Emergency
Vacation
Other
Briefly explain the reason for your leave
*
How will your absence impact your work schedule or duties?
Submit Leave Request
Should be Empty: