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VERSAC M LLC

TIME OFF REQUEST & SICK TIME NOTIFICATION FORM

Date: Name: Requested Date Off: Reason: -----*-----*-----*----- For Versacom Official use only -----*-----*-----*----Request Approved: Manager Name: Manager Signature: Complete this form for time off spent from work for doctor appointments and vacation time. If sick time is taken, you are required to submit this form when you come back. Submit this request at HQ for approval prior to requested time off. After processing you will receive a copy and the original will be provided to Human Resources for file placement. Denied:

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