Test Time Off Request
Name: 


A red asterisk (*) indicates required questions.

  1. What are you requesting?*
    Vacation 4 Hours
    Vacation 8 Hours
    Bereavement
    Jury Duty
    Unpaid Time Off 4 Hours
    Unpaid Time Off 8 Hours
    Other


  1. If "Bereavement," please indicate the relationship below.


  1. If "Other" (partial day) please indicate reason.
    Arriving Late
    Leaving Early
    Leaving During Shift and Returning
    Court
    Medical


  1. If "Partial Day" is selected, indicate for 1st half or 2nd half of the day. Also, please include the timeframe that you will be arriving, leaving and/or returning.


  1. Total Number of Days Requested:*


  1. Date Beginning:*


  1. Return to Work Date: *


  1. Comments:





Kelly Bishop