Employee Time Off Vacation Request Form
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1Time off Request Form
Company______
Employee’s Name: _________________________________ Date: _______________
# of Days /Hours: ___________ / ____________
Please indicate one or more of the following, with dates for each category used:
Denied Approved
Authorized By/Date:
___
Vacation* 1
Option : _______________ To: _______________
____________________
st
(Date)
(Date)
2
Option : _______________ To: _______________
____________________
nd
(Date)
(Date)
___
Maternity Leave**
_______________ To: _______________
____________________
(Date)
(Date)
___
Sick Leave
_______________ To: _______________
____________________
(Date)
(Date)
___
Jury Duty
_______________ To: _______________
____________________
(Date)
(Date)
___
Leave of Absence
_______________ To: _______________
____________________
(Date)
(Date)
___
Bereavement Leave
_______________ To: _______________
___________________
(Date)
(Date)
___
Other: ____________ _______________ To: _______________
___________________
(Date)
(Date)
Employee Signature: ________________________
Date: _______________
Planned time off will be granted on the condition that all reports, paperwork, and makeups are completed
before time off date, or arrangements are made for such work.
*
Form must be submitted at least 1 month before requested vacation start date.
** Please submit a copy of the signed doctor/medical excuse along with this form.
For office use only
Qualifying Period
Hrs of Vacation earned
Vacation Taken
Balance Due
To
To
To
To
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Parent category: Business