Paid Time Off Form
For Internal Company Use Only
Date Submitted
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
Minutes
AM
PM
AM/PM Option
Your Name
*
First Name
Last Name
PTO Start Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
PTO End Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time Left (except for full days)
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Arrival Time (except for full days)
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
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
Should be Empty: