Time Off Request Form

Employee Name: Jamie Sablich Request Date: Jan 13, 2017

Employee Number: 14004 Start Date: Mar 26, 2017 Week Ending Date: Apr 1, 2017

Department: Headstart

# of Days/
Choose One Choose Date Hours Choose One Time In Choose One Time Out Choose One
Personal Time Hours A.M.

Personal Time Hours

*If requesting the use of donated hours, employee must already have the donated hours. This form is not a request for donated hours.

Select the Date you

Additional will be returning to
I will Be coming in some days next week.
Information work

Add or Change Punch Date Time In AM/PM Time Out AM/PM

Additional
Information for
time off or punch
change

Supervisor's Name (Typed or Signed):

Approved Denied Denial Reason:

6-2-15/mam
Date: Print Form