Time Off Request

Name *

Name

First Name

Last Name

Type of Leave *

Sick leave (Illness or Injury)

Bereavement leave (Immediate Family)

Bereavement leave (Other)

Personal leave

Jury duty or legal leave

Emergency leave

Temporary leave

Leave without pay

Reason for Leave *

Leave Date *

Leave Date

MM

DD

YYYY

Return Date *

Return Date

MM

DD

YYYY

Leave Time *