Submit this completed form to your supervisor in advance of the dates requested. Provide up to three date options in order of

preference so an alternative can be considered if the first is unavailable. Requested time off is not approved until the supervisor

section is signed and dated.

S E C T I O N 1 — E M P LOY E E I N F O R M AT I O N

S E C T I O N 2 — D AT E S R E Q U E S T E D

List order of preferences

FIRST CHOICE

SECOND CHOICE

THIRD CHOICE

S E C T I O N 3 — R E A S O N F O R T I M E O F F