LEAVE NOTIFICATION

Date Submitting:  

Name: 

Title:  

TO:   Mark Stillwell CM Regional Director

This is to notify you that I plan to take (check one):

____ Personal Day        

____ Vacation Leave 

____ Family Medical Leave     

Date(s):    

(hours) From:   To:   

Total Number Hours (Days):  

In emergency, I can be reached at or through:

                                                                                                                                                    

                        ACKNOWLEDGEMENT


Date:  
   
Signature:   
  
          REGIONAL DIRECTOR 


Electronic Form   UM-SE 85 (Revised 4/99)