Time Off Request

Date * +

Employee's Name *

Number of days requested *

Request from * +

Request to * +

Reason for Request *

Comments *

Compensation Request for Time Off *

Paid Time Off

Unpaid Time Off

Supervisor Name *

I attest that the information that I have provided is accurate, and I understand that if I have not earned enough hours of ETO to be compensated then I will not be paid for the time I requested off. Time off requests do not guarantee approval. Considerations are based on staffing needs. *

Yes

No