* = Required Information
Employee Information
Name
*
Today's Date
Number of Days Requested
Starting On
Ending On
I Will Return to Work On
Type of Request
Vacation
Jury Duty
Late
Personal Leave
Family and Medical Leave
Funeral or Bereavement Leave
Time off to Vote
Other
Other (please specify)
Comments
Employee Certification
I understand that time away from work is subject to approval.
*
Employee Full Name
*
Date
Submit