Paid Time Off Request

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Paid Time Off Request
I am requesting: (
check one box)
Paid Time Off (PTO)
Bereavement Time Off
Immediate family only – spouse, children, parents and in-laws, siblings or siblings of one’s spouse,
grandparents and grandchildren – See BBCBC Employee Handbook.
Time Off Without Pay
Family/Medical Leave Act (FMLA) Time Off
See page 2 for more information. For approval of FMLA time off requests, this form must be
delivered to Human Resources, through your supervisor or their designee, within 24 hours of
signing.
Other Time Off
.
Jury Duty, military leave, leave of absence, etc. Please specify:
For the following dates:
through
for a total of
hours.
I understand that if I do not have sufficient accrued leave available when checked by Human
Resources, this time will be leave without pay. Exception to carry negative leave balances must
be approved by the CEO in advance.
Employee
Name:
Signature:
Date
Approved by:
Date
Supervisor, Director or CEO
Routing:
This form must be completed by the employee and approved by the employee’s
supervisor. Original Request Forms must be submitted to the Human Resources
office with the employee’s timesheet for the pay period in which the leave is
taken. Employees should retain a copy of the Request.
Cancellation: To withdraw or cancel this PTO Request, sign below and provide this form
with an original signature to Human Resources. Employees should provide a
copy to their supervisors and maintain a copy for their records. Cancellation
must be received prior to the requested PTO date.
Employee
Date
Signature:
Please cancel the above Paid Time Off request.
1100-1128 x Paid Time Off Request Form
Page 1 of 2
Updated 8/2009

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