Start Date Personal

Employee Personal Leave of Absence Application

Name: Hub Group Office: Department: Home Number: Cell Number: Current Address: Start Date of Personal Leave: Anticipated Return to Work Date: Reason for Leave (Explain):

Note: Once you are no longer receiving a paycheck from Hub Group, any missed benefit deductions will be accrued and due immediately upon your return to work and will be caught up through additional payroll deductions. A personal leave cannot exceed 30 consecutive days in length. It is up to your manager’s discretion as to how much of that 30-day duration is approved based on business needs. I understand that failure to return to work at the end of my personal unpaid leave period may be treated as a resignation from Hub Group.

Signature Date

Manager Signature Date

Company Use Only

Received by: Name Date