Name *

First

Last

Supervisor's Name

Employment StatusFull TimePart time

Requested Date(s) Off Starting On: *

Requested Date(s) Off Returning On: *

Do you have an alternate choice of dates?

• Yes
• No

Alternate Date(s) Off Starting On:

Alternate Date(s) Off Returning On:

Reason For Request *VacationPersonal LeaveSick DayFuneral/BereavementJury DutyTo VoteFamily ReasonsMedical LeaveStudy LeaveOther

If 'Other', please explain:

I understand this request is subject to approval (inital): *

Date *

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