* Required Information
Date Request Submitted
Request Submitted To
*
I,
request the following day(s) off:
Date(s)
Day(s) of week
Shift (if applicable)
Date(s)
Day(s) of week
Shift (if applicable)
I request that this be charged to one of the following
Personal Leave
Sick Leave (4 hour notice)
Military Leave - Without Pay
Jury Duty - Without Pay
Bereavement Leave - Without Pay
Vacation Leave
Other
Personal Leave
With Pay
Without Pay
Sick Leave
With Pay
Without Pay
Coverage Arrangements
Swap Arrangements
Signature of Employee(s) (Both employees must sign for a swap)
Signature
Clear
Signature
Clear
Supervisor's Approval
Director's Approval
Note: Vacation, personal and/or compensation time require a two weeks notice and written approval from your supervisor.
Sick time and in some cases, compensation time, may be granted on an emergency basis upon request.