REQUEST FOR TIME OFF
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.
***