Time Off Request Form
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Time Off Request
Please Check One:
[__] Vacation
[__] Personal Holiday
[__] Sick Leave
[__] FMLA
[__] Leave w/o Pay
[__] Summer Leave
[__] Other
Other: _________________________
________________________________
________________________________
Name: _________________________
Date Submitted: ____/____/_____
Total Number of Days Requested: _____
Starting Date: ___/___/_____
Return to Work: ___/___/_____
Approved By:
_______________________ Date_____
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