TOWN OF PITTSFIELD Sample Clauses

TOWN OF PITTSFIELD. APPLICATION FOR LEAVE OF ABSENCE Name: Department: Classification and Title: Date of Hire: Purpose for Which Leave is Requested: Dates of Leave: From: To: I understand that time spent on leave of absence is not considered time worked, that I must make arrangements with the Town for the payment of the total premiums of my group insurance coverage for the period of this leave of absence and that failing to return to work at the expiration of an approved leave of absence shall constitute a voluntary termination of my employment with the Town of Pittsfield, and that acceptance of employment while on leave of absence (except military or educational leave) constitutes a voluntary resignation of my employment with the Town of Pittsfield. Date SIGNATURE OF APPLICANT FOR LEAVE Department Head’s Recommendations: (Attach completed letter of transmittal and all supporting documentation). Date DEPARTMENT HEAD’S SIGNATURE Date TOWN ADMINISTRATOR’S SIGNATURE Approved: Board of Selectmen DATE: BOARD OF SELECTMEN REQUEST FOR FAMILY/MEDICAL LEAVE Employee Name: Date of Request: Department: Position Title: Date of Hire: I request a Family/Medical Leave for the following reason (check one)