Time Off Request Form

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1. Employee Name:

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2. Employee Phone Number:

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3. Employee Email:

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4. Manager Name:

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5. Manager Phone Number:

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6. Manager Email:

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7. Department:

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8. Date of Request:

Date / Time

Date

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9. Requested leave start date:

Date / Time

Date

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10. Requested return date:

Date / Time

Date

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11. Type of leave requested:

Vacation leave

Sick leave

Bereavement leave

Jury duty

Parental leave

FMLA leave

Leave without pay

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12. Type of leave explanation: