REQUEST FOR TIME OFF

EMPLOYEE NAME:
DEPARTMENT:
BADGE #:

REQUEST FOR TIME OFF:

Dates FROM:		THROUGH:
TIME FROM:		THROUGH:

AMOUNT OF TIME OFF: DAYS HOURS (indicate which)

REASON: PTO-VACATION PTO-HOLIDAY PTO-PAYCHECK TO 80 HRS PTO-SICK PTO-UNSCHEDULED TIME OFF BEREAVEMENT (does not deplete PTO accrual) JURY DUTY (does not deplete PTO accrual) UNPAID TIME OFF

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