Time-Off Request Form

COMPANY NAME/LOGO

EMPLOYEE REQUEST FOR TIME OFF



Your request for time off must be submitted and approved by management at least [# of

weeks] weeks prior to your requested time off start date.

EMPLOYEE INFORMATION

EMPLOYEE NAME: SUPERVISOR NAME:



REQUEST DATE: DEPARTMENT:



NUMBER OF DAYS REQUESTED: NUMBER OF HOURS REQUESTED:



TIME OFF STARTING ON: TIME OFF ENDING ON:



RETURNING TO WORK ON:





REASON FOR REQUEST



VACATION MILITARY



PERSONAL FAMILY AND MEDICAL



BEREAVEMENT SICK TIME



JURY DUTY TIME OFF TO VOTE





EMPLOYEE CERTIFICATION



I understand that my request for time off from work is subject to management approval and company

policies.





EMPLOYEE SIGNATURE: ______________________________________ DATE: ____________________





APPROVAL



APPROVED: YES NO





COMMENTS:









SUPERVISOR SIGNATURE: _____________________________________ DATE: ____________________





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