Time-Off Request (new)

Time-Off Request

Updated 07.17.23
I am requesting...*

Paid Leave (If Available)Unpaid Leave
Employee Name*
Department
Date Employment Started

MonthDayYear
Date
Date(s) requested off*
Type it like this: 08.21.21-08.22.21
Total Hours-Off Requested*
Last Day to be Worked*

MonthDayYear
Date
Return Date*

MonthDayYear
Date
Reason for Request:

VacationMedical / DentalChild-Related (sick, doctor, etc)Personal Day / SickOther (detail below)
Details (if needed):
Include exact times you will be away from work in this box if you are not missing an entire day.
If you are taking a half-day, choose one:

I will miss the first half of the dayI will miss the last half of the day
Alternate Contact Information:
(If your regular contact information will not work)
Signature
Date

MonthDayYear
Date
Should be Empty: