"Time off Request Form"

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Time-Off Request Form
Employee Name: ______________________________
Date Submitted: _____/_____/_____
Supervisor: ______________________________________
Please schedule your time off requests as far in advance as possible. The Company reserves the right to approve or
disapprove time off requests. Time Off requests will be reviewed and considered for approval on a “First come, First granted”
basis. Employees are required to request their vacation/time off requests in writing at least four weeks in advance, unless your
absence is due to an emergency. Should more than one employee request the same time off, the employee who first
requested the time off (submitted) will be considered for approval first.
Reason For Absence: _____________________________________________________
Additional documentation and/or explanation may be required for some absences.
Requested Date/Time off Absence:
Starting Date:
_____/_____/_____
Time: _____________ [ ] am [ ] pm
Back to work on:
_____/_____/_____
Time: _____________ [ ] am [ ] pm
Total Hours Requested: ___________
Request Type: [ ] Vacation Time [ ] Sick/Medical
[ ] Volunteer Time Off
[ ] Holiday
[ ] Bereavement
[ ] Jury Duty/Witness
[ ] Other ________________________
Person(s) Covering Duty(s)
Duty(s) being Covered:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Special Duty(s) to be covered while off:___________________________________________________________
__________________________________________________________________________________________
Employee Signature: _____________________________________
Date _____/_____/_____
[ ] APPROVED
[
] DISAPPROVED [ ] MODIFIED APPROVAL as follows: __________________________
Supervisor Signature: _____________________________________
Date _____/_____/_____
OFFICE USE ONLY:
[ ] Vacation Time
YTD: ___________
[ ] Time Off with Pay
[ ] Sick/Medical
YTD: ___________
[ ] Time Off Without Pay
[ ] Volunteer Time Off
YTD: ___________
[ ] Holiday
YTD: ___________
[ ] Bereavement
YTD: ___________
[ ] Jury Duty/Witness
YTD: ___________
[ ] Other _________________ YTD: ___________
Time-Off Request Form
Employee Name: ______________________________
Date Submitted: _____/_____/_____
Supervisor: ______________________________________
Please schedule your time off requests as far in advance as possible. The Company reserves the right to approve or
disapprove time off requests. Time Off requests will be reviewed and considered for approval on a “First come, First granted”
basis. Employees are required to request their vacation/time off requests in writing at least four weeks in advance, unless your
absence is due to an emergency. Should more than one employee request the same time off, the employee who first
requested the time off (submitted) will be considered for approval first.
Reason For Absence: _____________________________________________________
Additional documentation and/or explanation may be required for some absences.
Requested Date/Time off Absence:
Starting Date:
_____/_____/_____
Time: _____________ [ ] am [ ] pm
Back to work on:
_____/_____/_____
Time: _____________ [ ] am [ ] pm
Total Hours Requested: ___________
Request Type: [ ] Vacation Time [ ] Sick/Medical
[ ] Volunteer Time Off
[ ] Holiday
[ ] Bereavement
[ ] Jury Duty/Witness
[ ] Other ________________________
Person(s) Covering Duty(s)
Duty(s) being Covered:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Special Duty(s) to be covered while off:___________________________________________________________
__________________________________________________________________________________________
Employee Signature: _____________________________________
Date _____/_____/_____
[ ] APPROVED
[
] DISAPPROVED [ ] MODIFIED APPROVAL as follows: __________________________
Supervisor Signature: _____________________________________
Date _____/_____/_____
OFFICE USE ONLY:
[ ] Vacation Time
YTD: ___________
[ ] Time Off with Pay
[ ] Sick/Medical
YTD: ___________
[ ] Time Off Without Pay
[ ] Volunteer Time Off
YTD: ___________
[ ] Holiday
YTD: ___________
[ ] Bereavement
YTD: ___________
[ ] Jury Duty/Witness
YTD: ___________
[ ] Other _________________ YTD: ___________