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Employee Time Off Request Form

Employee’s Name: _______________________________________________________

Employee’s Manager: _______________________________________________________

Time-Off Request: ___________ 𝤿 Days 𝤿 Hours

Beginning on: _______________________________________________________

Ending on: _______________________________________________________

Reason for Request

𝤿 - Vacation 𝤿 - Personal Leave 𝤿 - Funeral / Bereavement

𝤿 - Jury Duty 𝤿 - Family Reasons 𝤿 - Medical Leave

𝤿 - To Vote 𝤿 - Other: _______________________

I understand that this request is subject to approval by my employer.

Employee’s Signature:______________________________________________ Date:_____________________________

_________________________________________________________

Employer’s Decision

𝤿 - Approved 𝤿 - Rejected

Employer’s Signature: _______________________________________________ Date: ___________________________

Print Name: ___________________________

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