Time Off Request Form

Time Off Request
Name*

First NameLast Name
Today's Date

MonthDayYear
Date
First Date Off*

MonthDayYear
Date
Last Day Off*

MonthDayYear
Date
Date available to return to work*

MonthDayYear
Date
Time Off Code*
Are you vacationing outside of the United States?*

YesNo
If you are vacationing outside of the United States, which country are you going to?
For Caregivers with Health Insurance Benefits:
If you are going on extended leave, YOU MUST MAKE ARRANGEMENTS FOR CONTINUED COVERAGE IN ADVANCE OR RISK LOSING COVERAGE.
PTO cannot be used December 22-January 1Last day to request ALL end of the year Time OFF Request is November. After this date no Request will be approved
I acknowledge that any unused PTO will not be paid or carried over*

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Signature*

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