Time Off Request Form
*Remember: Time off requests will only be considered when submitted 10 days in advance.
Name
*
First Name
Last Name
Date of Submission
*
/
Month
/
Day
Year
Type of Request (select one):
*
Vacation
Medical (Please Note: Doctor's notes will be required 24 hours after your appointment.)
Other Employment
I need to request off for... (select ONE)
*
...one day.
...a date range. (*This option is for vacations only.)
Date Requested (Weekends are considered for vacations ONLY)
*
/
Month
/
Day
Year
Start Date:
*
/
Month
/
Day
Year
End Date:
*
/
Month
/
Day
Year
Time of Appointment:
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
Reason for Request:
*
Attachments:
*
Attach Other Employment Schedule
Submit for Consideration
Should be Empty:
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