Employee Full Name*First NameLast NameBeginning OnMonthDayYearat 123456789101112Hour001020304050MinutesAMPM Ending OnMonthDayYearat 123456789101112Hour001020304050MinutesAMPM Reason for Request*Personal LeaveFuneral / BereavementJury DutyMedical LeaveType of RequestPlease count towards my paid PTOPlease do NOT count towards my paid PTOCommentsI understand that this request is subject to approval by my supervisor.Signature*SubmitShould be Empty: This page uses TLS encryption to keep your data secure.
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