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Time Off Request Form

This form should be completed and submitted to your manager at least 2 weeks prior to your requested time off.

Employee Name: ___________________________________________________________


Day(s) Requested: through

If Requesting partial day - Please indicate: AM __________ or PM __________ Time off should be recorded as: Vacation Sick Total Hrs Total Hrs

Other Total Hrs - Other please describe

Employee Signature Approved by:

Date

Manager

Date

VP, COO Reason for Denial:

Date

Administration Use Only: Date added to Vacation Calendar Remaining paid Hours available: Previously scheduled dates: Also requesting these dates: Time Off if approved will be: Paid Unpaid By: As of: Total Hrs Total Hrs By:

Additional Notes:

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