Request for Military Leave Name * Employee ID# * Address * City * State * Zip * Type of Military Leave * Annual Reservist Training Military Duty Dates of Leave Begin Date * Expected End Date * Certification of Employee I hereby certify that I have been called to service in the uniformed services and request leave from the University for the dates set forth above. I understand that if I return to work within the time periods set by the Uniformed Services Employment and Reemployment Rights Act (“USERRA”), I will be returned to a position with the University as provided by law. I understand that if my leave is more than 30 days, I will not be eligible to continue certain benefits through the University. I have contacted or will contact the Benefits Department regarding my employee benefit participation. (Review the Benefits for University of Utah Employees on Military Leaves of Absence form for additional information.) Complete for Active Military Duty Only: Employees who elect to use accrued vacation and personal preference leave must use it at their full regular schedule (e.g., if the employee is regularly scheduled to work 40 hours per week, 40 hours of accruals must be used each week until exhausted). I wish to use the following accrued vacation and personal preference leave time during my leave: * All vacation and personal preference leave time All personal preference leave time All but - mention hours of vacationAll but - mention hours of vacation None (I wish to take all leave unpaid) Employee Signature * Employee Signature First First Last Last Date * I hereby certify that I have been called to service in the uniformed services and request leave from the University for the dates set forth above. I understand that if I return to work within the time periods set by the Uniformed Services Employment and Reemployment Rights Act (“USERRA”), I will be returned to a position with the University as provided by law. I understand that if my leave is more than 30 days, I will not be eligible to continue certain benefits through the University. I have contacted or will contact the Benefits Department regarding my employee benefit participation. (Review the Benefits for University of Utah Employees on Military Leaves of Absence form for additional information.) Complete for Active Military Duty Only: Employees who elect to use accrued vacation and personal preference leave must use it at their full regular schedule (e.g., if the employee is regularly scheduled to work 40 hours per week, 40 hours of accruals must be used each week until exhausted). I wish to use the following accrued vacation and personal preference leave time during my leave: Department Information Supervisor's Name: * Supervisor's Campus Address * Department Payroll Reporter's Name Supervisor's Phone Number: * Department Payroll Reporter's Phone Number: I have reviewed the employee’s military orders and confirm that the employee has been ordered to duty for the dates stated above. I acknowledge that I have reviewed the department’s responsibilities on this form and that this department will comply with those requirements. Supervisor's Signature * Supervisor's Signature First First Last Last Date * If you are human, leave this field blank. Submit Start Over Δ
