Time-Off Request Form printable pdf download

TIME‐OFF REQUEST FORM

EMPLOYEE INFORMATION

Name: ______________________________________________________________________

(please print)

Today’s Date: _______________________________________

Number of hours requested: ___________________________

TYPE OF REQUEST

PLEASE APPLY TIME‐OFF TO:

___VACATION ___SICK TIME ____COMP TIME ____JURY DUTY __ __FAMILY/MEDICAL LEAVE

_____ BEREAVEMENT/FUNERAL LEAVE

(IMMEDIATE FAMILY / MAX OF 3 DAYS PAID)

PLEASE CIRCLE: Spouse, Child, Parent, Sibling, Grandparent, Grandchild, In‐Law of same degree

Days & Hours Off

Date

Day

Time Off

Please list the dates,

(MM/DD/YY)

(e.g. Monday)

Start

End

days, and times that

you would like to

take off.

EMPLOYEE CERTIFICATION



I understand that time away from work is subject to management approval and company policies.



All requests must be submitted in advance, when possible.



An employee who uses more than his or her annual vacation hours shall have the overage deducted from the employee’s monthly

pay. Employees shall be paid only for hours worked or for leave earned.



A new employee will receive 40 hours of vacation after a 6 month waiting period, which becomes available the first day of the

month immediately following the 6 month waiting period.



Accrued vacation expires the last day of the month prior to the employee’s anniversary. The policies do not allow for rollover

from year to year.



Upon approval, request forms should be submitted to HR for posting.

Employee Signature: _________________________________________ Date: _____________________

APPROVED:

YES

Supervisor/Manager Approval:

Date:

Payroll Input:

Date:

Time-Off Request Form

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