Vacation/leave Request Form
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1Vacation/Leave Request Form
Employee to Complete
Employee Name _________________________________________________________
Supervisor/Manager
_____________________________________________________
Status (select one)
Full-time
Part-time
Dates and/or Time off requested ___________________________________________
Reason for Requested Time off
Refer to your employee handbook for state, federal, and company leave policies.
For questions regarding your company’s leave policies, consult with your
supervisor/manager.
Vacation
Sick
Other: _
___________________________________________________________
Employee Signature _____________________________________
Date _________ / ________ / _______
---------------------------------------------------------------------------------------------
Employer to Complete
If request for leave is for an FMLA-qualifying reason, employee should also complete the
Request for Family/Medical Leave Under the FMLA.
Request Approved
Request Denied
Supervisor/Manager Signature _____________________________________
Date _________ / ________ / _______
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Parent category: Business