Division of Student Affairs

Date*
Date Format: MM slash DD slash YYYY
Name*
First Last
Email Confirmation*
Enter Email Confirm Email
Check appropriate box to indicate department*
- Bookstore
- Campus Life
- Dining Services
- Disability Resource Center
- Housing
- Health Services
- Judicial/Budgetary/Administrative Affairs
- Vice Provost for Student Affairs Office
- Others
Other Department
Beginning Date of Request*
Date Format: MM slash DD slash YYYY
Concluding Date of Request*
Date Format: MM slash DD slash YYYY
Total Number of Hours Requested*
Type of Leave*
- Amended Leave Request
- Vacation
- Sick
- Leave without pay
- FMLA
- Authorized leave (specify in "Other" box)
- Professional Development (specify in "Other" box)
- Other
With the exception of sick leave, this form must be approved before the leave commences. For sick leave, request form may be submitted upon return to work.
Agreement*
- Yes
I acknowledge that by submitting this form that all information shared is accurate.
Phone
This field is for validation purposes and should be left unchanged.

UA Little Rock Public Radio
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