Employee Time-Off Request Form

Employee Time-Off Request Form
Employee Name: *
Time-Off Request Date:

Month Day Year
Date
Last Day of Dispatch:

Month Day Year
Date
End Time:

: Hour Minutes
Available for Dispatch:

Month Day Year
Date
Start Time:

: Hour Minutes
Reason for Request:

Vacation Personal Leave Funeral/Bereavement Jury Duty Family Reasons Medical Leave To Vote
How I would like paid:

Vacation Sick No Pay
I understand that this request is subject to approval by my employer.
Employee's Signature *

Clear
Signature Date:

Month Day Year
Date
Should be Empty:

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