Employee Leave Request FormEmployee Name(Required) First Last DepartmentSupervisor NameReason For Time-Off(Required) VACATION SICK - Self SICK - Family SICK - Dr. Appt. WORKERS COMP CIVIL/JURY DUTY MILITARY FAMILY and MEDICAL FUNERAL - Relationship LEAVE OF ABSENCELEAVE REQUESTEDStarting Date(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Starting Time Hours: Minutes AMPM AM/PMEnd Date(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920End Time Hours: Minutes AMPM AM/PMTotal HoursTotal DaysOtherSupporting Documents Drop files here or Select filesMax. file size: 100 MB.Date MM slash DD slash YYYY Employee SignatureΔ
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