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Request for Time Off - DOC

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					                                  Request for Time Off
Name _______________________________________________________________________

Department __________________________________________________________________

REASON                 DATE(S)                     # OF DAYS          # OF HOURS

Paid Time Off          _______________             _________          __________

Sick Leave             _______________             _________           __________

Comp Time              _______________             _________          __________

Annual Military Duty   _______________             _________           __________

Jury Duty              _______________             _________          __________

Death in Family          _______________           _________          __________
(specify relationship below)

Other (explain below) _______________              _________          __________

                                 TOTAL TIME OFF:   _________           __________

FURTHER EXPLANATION (when required)
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Employee signature ______________________________________             Date _______________


SUPERVISOR’S RECOMMENDATION:                       COMMENTS:
    Approved:                                     ____________________________________
    Approved with following modification:         ____________________________________
    Unapproved for following reason:              ____________________________________

Supervisor’s signature ___________________________________      Date __________________
WHITE COPY: Supervisor YELLOW COPY: Staff Member

				
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