DARTON COLLEGE

LEAVE REQUEST

_______________________________ ______________________________

Employee Name Social Security Number

Period of Absence: Beginning ________________ Ending _________________

Reason for this absence: ________________________________________________

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________________________________________________

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During this absence, my teaching or other duties will be taught or covered as indicated.

Day Class Room Hour To be taught or covered by

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________________________________________________________________________

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(Continue on back of this sheet, if necessary)

Approval:

_______________________________ ______________________________

Employee Signature Date Division/Department Head Date