To:

Dear ____________:

The undersigned hereby requests absence or leave from my employment for purposes of temporary active military duty from ________, 20 _, to ________, 20 _.

I certify that I am a member of the _____________________, I understand that if my military base pay ior this period is less than my regular salary, I will be reimbursed for the diiference for a period not to exceed ( ) work weeks ( ) days. I agree to furnish you a copy of my military pay statement immediately upon receipt with adjustments in salary to be made from my next paycheck.

Furthermore, I agree to iurnish the company a copy of my orders to report for service or such other appropriate certification of duty as the company may require.

________________________

Employee