Military Leave Notice Form

A form for employees to notify HR of military leave, provide order dates, and document USERRA-related benefits and reinstatement details.

Employee Information

• Full Name
• Employee ID
• Department
• Work Location
• Preferred Contact Email

Military Leave Details

• Leave Type
• Date Notice Provided
• Leave Start Date
• Expected Leave End Date
  If the end date is unknown, leave this blank and provide the best available estimate in the notes below.
• Branch of Service
• Reason for Leave

Military Orders and Documentation

• Have you received military orders or official notice?
• Upload Orders or Notice
  Upload a copy of your orders or official notice if available. Accepted file types: PDF, JPG, PNG.
• Orders Issue Date
• Military Contact for Verification
  Optional contact name or office for HR verification if needed. Do not include unnecessary personal information.

USERRA Benefits and Leave Coordination

• Do you need benefits continuation during leave?
• Questions or Requests About Benefits, Pay, or Leave Balances
• Would you like to use accrued paid leave, if permitted?
• I understand HR will coordinate leave and benefits in accordance with applicable policy and USERRA requirements.

Return to Work and Reinstatement

• Expected Return-to-Work Date
• Reinstatement or Scheduling Needs
• Additional Return-to-Work Notes
• Employee Signature
  Optional signature if your organization uses signed leave notices.