EMPLOYEE LEAVE AUTHORIZATION 3-5-2A

Employee’s Name: Kolder, Rudolph Emp. #: 14780351

Work Location: LaPalmaCC Date Submitted:

Please enter the amount of paid hours needed and the type of leave requested in the appropriate box.
PTO Hours: Sick Bank Hours: Bereavement Hours:
(Accrued PTO must be exhausted first)
Holiday Hours: What Holiday?
FMLA Leave (please check applicable reason): Personal Illness*? Family Illness*? Parental?
Military Leave** Hours: Civil Leave** Hours:
* For FMLA, a Certification of Health Care Provider is required and should be submitted with this form.
** Military and Civil Leave will require written documentation of absence.
Please list the dates on which these hours were taken:

In the event that my employment terminates for any reason, by my signature below, I authorize CoreCivic to deduct from my final pay a monetary amount equivalent
to any pay advance for the above hours not offset, in accordance with applicable federal and state law.

Employee’s Signature: Date:

Supervisor’s Signature: Date:

Entered into time clock by: Date:

Approved: Denied:

04/24/2017

________________________________________________________________________________________

EMPLOYEE LEAVE AUTHORIZATION 3-5-2A

Employee’s Name: Kolder, Rudolph Emp. #: 14780351

Work Location: LaPalmaCC Date Submitted:

Please enter the amount of paid hours needed and the type of leave requested in the appropriate box.
PTO Hours: Sick Bank Hours: Bereavement Hours:
(Accrued PTO must be exhausted first)
Holiday Hours: What Holiday?
FMLA Leave (please check applicable reason): Personal Illness*? Family Illness*? Parental?
Military Leave** Hours: Civil Leave** Hours:
* For FMLA, a Certification of Health Care Provider is required and should be submitted with this form.
** Military and Civil Leave will require written documentation of absence.
Please list the dates on which these hours were taken:

In the event that my employment terminates for any reason, by my signature below, I authorize CoreCivic to deduct from my final pay a monetary amount equivalent
to any pay advance for the above hours not offset, in accordance with applicable federal and state law.

Employee’s Signature: Date:

Supervisor’s Signature: Date:

Entered into time clock by: Date:

Approved: Denied:

04/24/2017