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Time Off Request Form

Employee Name

First Name

Last Name

Today's Date

YYYY

Date for Requested Time Off

YYYY

Additional Dates

If more than one day is requested off, please enter additional dates here.

If More Than One Day, Enter Additional Dates Here

Time Requested Off

Reason for Time Off

Sick Day

Funeral

Vacation

Dr. Appt (Self)

Dr. Appt (Family)

Other

Other Information

If you selected "Other" as reason for time off request, please explain here.

Employee Verificiation

By selecting "Yes," I'm officially requesting time off for the information above.