Employee Time Off Request

Please fill out this form if you would like to request time off for appointments, vacations, etc. Remember, you are not approved until you receive a message from admin staff with approval.

Name *

First

Last

Email *

Today's Date

TIME OFF BEGINNING ON:

AVAILABLE TO RETURN TO WORK:

Reason or Request (Check all that apply):

• Personal Time Off
• Leave of Absense (>30 days)
• Bereavement
• Medical Leave of Absence
• Dr./Dental Appointment
• Sick Pay Request
• Other

Comments Regarding Request:

Requestor's Signature:

Clear Signature

FOR OFFICE USE ONLY

• APPROVED
• DENIED

Date of Approval

Approved By

First

Last

Comments

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