DUI Program – Leave of Absence (LOA) Request

You may submit this form to request a Leave of Absence (LOA) for the following reasons:

You must submit the request for the LOA at least 24 hours in advance of the leave. You must submit documentation proving the reason for the request.

Submitting this form does not automatically result in approval for your leave of absence. You will receive an email or call from our office confirming the LOA once approved.

The fee for a Leave of Absence is $25.00. All activities missed while on an LOA must be made up at the end of your program. You must continue to make any scheduled program payments while on an LOA.

If you are unable to attach proof to this request, you may fax, mail, email, or bring the proof to our office prior to the commencement of the LOA. If we do not receive proof we will not be able to approve the LOA.

Section 1: Client Information

Full Name: *

Email Address: *

Confirm Email Address: *

Primary Phone Number *

Section 2: Program Location

Identify which Sacramento County Breining Institute DUI Program location you are attending: *

NORTH COUNTY: 8894 Greenback Lane, Orangevale

FOLSOM: 2360 E. Bidwell Street, Suite 107, Folsom

MID-COUNTY: 2775 Cottage Way, Suite 25, Sacramento

SOUTH COUNTY: 3159 Dwight Road, Suite 100, Elk Grove

What is the starting date for your requested Leave of Absence? *

What is the ending date for your requested Leave of Absence? *

Identify the reason you are making this request for a Leave of Absence.

You may select more than one reason.

Travel for work.

Military duties.

Illness or family illness.

Incarceration including home arrest (the $25.00 fee is waived for incarceration LOAs).

Extreme personal hardship or family emergency.

Vacation (client must make up all absences and be up to date on all payments to request an LOA for this reason).

Other reason, identified below in Section 3.

Section 3: Other reason for Leave of Absence request.

If there is another reason you are requesting an LOA which is not identified above, please explain it here:

File Upload (if applicable)

If applicable, you may upload your documentation here:

Section 4: Credit Card and Payment Information

You give permission to and authorize Breining Institute to charge the twenty-five dollar ($25.00) Leave of Absence (LOA) fee to the following credit card:

Credit Card: *

VISA

MasterCard

Discover

Credit Card Number: *

Full Name on Credit Card: *

Credit Card Expiration Date *

Captcha *

reCAPTCHA is required.