Request for Leave of Absence and Advance Degree Leave
Institution: Delgado Community College Date: __________________________
Name of Employee: _________________________ Social Security No. _________________
Title: ______________________________________________________
Department: _______________________________
Highest Degree: _____________________ Birthday: Month____ Day____ Year ___ Age: ___
Number of Consecutive Fiscal Years Active Service with current employer: __________________________________________________________________________
Purpose of Leave Requested (Check one):
a. Advance Degree ______
b. Leave of Absence ______ _
Manner in which this leave, if granted, will be spent: (Also include information as to how the degree will benefit the work you perform for the College.)
______________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________
Effective Dates of Leave: Beginning __________________Ending ______________________
I have reviewed the RULES (Bylaws and Policies and Procedures) of the Louisiana Community and Technical College System, Policy # II.3.003, pertaining to Advances Degree Leave and Leaves of Absence and hereby agree to comply with the provisions enumerated therein.
________________________________________
Signature of Applicant
Prior Leave Record From this Institution (To be certified by the institution):
Date of Last Leave: _____________________ Length of Last Leave: _____________________
Type of Last Leave: With Pay __________ Amount $ ___________ Without Pay ____________
Type of Leave Recommended by Supervisor (Check One)
a. With Pay ______ % of Salary _____ Amount $_________
b. Without Pay ______
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Delgado Community College
LCTCS Form - Request for Leave of Absence and Advanced Degree Leave
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Approvals:
Note: Employee is responsible for submitting a signed Recommendation Letter from his/her Department Manager/Supervisor with this application to the Human Resources Department. This form will not be considered for approval without this documentation.
The supervisor is responsible for obtaining the signature of the Assistant Vice Chancellor for Financial Services of budgetary availability of funds for any instance where leave is recommended to be with pay.
______________ ________________________________________________________
Date Approved Signature of Employee’s Department Manager/Supervisor
______________ ________________________________________________________
Date Approved Signature of appropriate Vice Chancellor
______________ ________________________________________________________
Date Approved Signature of Assistant Vice Chancellor for Financial Services
_______________ ________________________________________________________
Date Approved Signature of Assistant Vice Chancellor for Human Resources
_______________ ________________________________________________________
Date Approved Appointing Authority for LCTCS
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