REQUEST FOR TIME OFF
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Today's Date: _______________________________

Name:_____________________________________

Title:______________________________________

I am requesting the following time off:

Dates:

From _____________________ through _______________________ (both inclusive)

Charge time to:

Person Assuming Responsibilites During My Absence:

__________________________________________________________

__________________________________________________________
Signature of Staff Member

__________________________________________________________
Signature of Immediate Supervisor or Department Head

***
Please turn in this form, complete with signatures,
to Administrative Assistant prior to taking any leave.
***

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