Paid Time Off Form
For Internal Company Use Only
Date Submitted
/
Month
/
Day
Year
Date
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:
Hour
00
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Minutes
AM
PM
AM/PM Option
Your Name
*
First Name
Last Name
PTO Start Date
*
-
Month
-
Day
Year
Date
Time Left (except for full days)
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
15
30
45
Minutes
AM
PM
AM/PM Option
PTO End Date
*
-
Month
-
Day
Year
Date
Arrival Time (except for full days)
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
15
30
45
Minutes
AM
PM
AM/PM Option
Type of Absence
*
Full-Day Absence
Mid-Day Absence
Came in Late
Left Early
Reason for Absence
*
Must Select
Vacation
Illness
Medical/Dental Appt
Personal Time
Jury Duty
Bereavement
Other (describe under Comments)
PTO Hours Used
*
Enter partial hour increments (15 min=0.25; 30 min=0.50; 45 min=0.75)
Apply To
Comments
Your E-mail
*
example@example.com
Submit
Clear Form
Print Form
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