HAS Leave of Absence Request

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Name and HAS Number of Member requesting LOA *

Requested start date of LOA *

YYYY

Expected end date of LOA *

YYYY

Reason for requesting LOA *

By checking the box below, I understand that my leave of absence is administrative in nature and my return to active status is contingent upon clearance by the training department and I may be required to demonstrate clinical skills or complete a refresher training prior to returning to full member status. *

I acknowledge and agree with this

I am required to return any HAS-issued equipment including, but not limited to pagers and radios prior to starting an approved LOA. Failing to return department-issued equipment may result in collections actions by the Town of Harvard. *

I acknowledge and agree with this

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