REQUEST FOR LEAVE

Name:__________________________________________ Date:_____________________________________

I am requesting time off as follows:

Vacation:

Personal:

Other (Specify):

Day(s):_____________________________________ Week(s):________________________________________
(INDICATE DATES)

(INDICATE DATES)

Recommended:________________________________ Date:________________________________________
(SUPERVISOR)

Approved:____________________________________ Date:________________________________________
(OFFICE ADMINISTRATOR**)

Comments:
**Please be advised that the approval of a vacation request is dependent upon the employee having already accrued vacation
time when it is requested, as well as when it is to be taken. Vacation approval can be rescinded if the employee has used some or
all of his/her accrued vacation time prior to the date his/her vacation is to commence.
Please return this form to the Office Administrator.