"Work Schedule Request Form" - Mississippi

Work Schedule Request Form is a legal document that was released by the Mississippi Department of Education - a government authority operating within Mississippi.

Form Details:

  • Released on July 1, 2017;
  • The latest edition currently provided by the Mississippi Department of Education;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Mississippi Department of Education.

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Revised 7/17
Mississippi Department of Education
Work Schedule Request Form
Name: ______________________________
Date: _______________________
Position: ____________________________
Office/Department: ___________________
Flexible Working Schedule Requested
___ 7:30 am - 4:30 pm
w/1hr lunch
___ 8:00 am - 5:00 pm
w/1hr lunch
___ 8:30 am – 5:30 pm
w/1hr lunch
________ Lunch Period (60 minutes)
________ End Time
_____________________________
___________________________
Employee (Print Name)
Signature & Date
_____________________________
Approved/Disapproved___________________________
Signature & Date
(Please Circle)
Signature & Date
_____________________________
Approved/Disapproved___________________________
Office Director (Print Name)
(Please Circle)
Signature & Date
Revised 7/17
Mississippi Department of Education
Work Schedule Request Form
Name: ______________________________
Date: _______________________
Position: ____________________________
Office/Department: ___________________
Flexible Working Schedule Requested
___ 7:30 am - 4:30 pm
w/1hr lunch
___ 8:00 am - 5:00 pm
w/1hr lunch
___ 8:30 am – 5:30 pm
w/1hr lunch
________ Lunch Period (60 minutes)
________ End Time
_____________________________
___________________________
Employee (Print Name)
Signature & Date
_____________________________
Approved/Disapproved___________________________
Signature & Date
(Please Circle)
Signature & Date
_____________________________
Approved/Disapproved___________________________
Office Director (Print Name)
(Please Circle)
Signature & Date