Time Off Request
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1
2Time Off Request
Please Check One:
[__] Vacation
[__] Personal Holiday
[__] Sick Leave
[__] FMLA
[__] Leave w/o Pay
[__] Summer Leave
[__] Other
Other:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Name: ________________________________________
Date Submitted: ____/____/_____
Total Number of Days Requested: _____
Starting Date: ___/___/_____
Return to Work: ___/___/_____
Approved By: ____________________________________________ Date: ___/___/_____
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Parent category: Business