EMPLOYEE LEAVE REQUEST FORM
PLEASE PRINT OR TYPE ALL INFORMATION
Last
First
Middle Initial
Employee Name: Client Name:
S.S. #:
Dates Requested: Total # of Hours Requested: Type of Leave:
Vacation
Paid
Unpaid
Personal
Sick
Reason for leave:
Employee Signature: Person Reporting Leave:
(Required if reported by someone other than employee)
Date: Date:
To Be Completed By Supervisor
Approved
Declined – Reason declined
Supervisor Signature:
Date: