Canada- Leave Request

Name

Empl.I.D.

Company

I am requesting time off from work beginning ___________________ and ending ___________________ for a
Date

Date

30
total of ___________________
hours as indicated below.

IMPORTANT:
You must submit this approved leave request
to your company HR Manager, who will be
responsible for reporting your time off to
TriNet.

Type of Leave Requested

Vacation
Hours ____
30
Sick

Hours ____

Floating Holiday

Hours ____

Other: (Explain)
Reason for Leave without Pay Request
Maternity / Parental Leave
(provide required written notice)

Disability (If more than 7 days, please advise

TriNet to apply for STD insurance)

X Personal

Unpaid Sabbatical

Bereavement

Other (Explain)

Leave without pay

In requesting the time off, I understand the following:
I must provide advance notice when my absence is foreseeable. My failure to do so may result in denial of my
request or a postponement of my time-off. I must provide supporting documents for time off requests for Jury
Duty or disability. I'm aware of and understand that I must first use any applicable vacation credit before I can
be placed on a leave without pay status. My Company will allow me the time off during the date(s) requested
when it is operationally feasible. My Company may deny my request based on the needs of the operation. I
understand that if I take vacation time that has not yet been earned or accrued, that it will be considered
advanced wages if approved by my company. As such, upon termination, I will be obligated to repay any
outstanding advanced wages through payroll deduction from my final paycheque. I must provide appropriate
medical certification, which is ____ is not ___ attached, when leave is due to my own health condition
for more than 3 consecutive days. (Approval of leave may be delayed pending receipt of the medical
certification.) I have a continuing obligation to pay my share of all group benefits, health, dental, life, and other
benefit plans insurance premiums, in which I have enrolled, in a timely manner during the leave, unless I
decline to continue my coverage during my leave as indicated by my written waiver. If my employer elects to
pay my portion of the premiums for any health, dental, life, and other insurance coverage during my unpaid
leave of absence, my employer is authorized to recover all costs paid on my behalf for maintaining my
insurance coverage in effect during my leave. I hereby agree that such sums can be recovered through payroll
deductions following my reinstatement if I do not make other arrangements with my employer. If I fail to report
for work as scheduled for three consecutive days at the end of my approved period of absence,
as indicated above, I will be considered to have abandoned my job and voluntarily resigned.
Employee Signature: ______________________________________ Date of Request: __________________

Supervisor Signature: ______________________________________________

Approved

Disapproved

Manager Signature: _______________________________________________

Approved

Disapproved

04/08/05 DB
CAN Leave Request

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