092319
EMPLOYEE TIME OFF REQUEST
EMPLOYEE INFORMATION
Name: _____________________________________ Dept: _________________
Job Title: __________________________________________________________
Supervisor Name: __________________________________________________
Starting date: ___________ Ending date: ____________
I will return to work on: _______________________
TYPE OF REQUEST
FUNERAL / BEREAVEMENT LEAVE
JURY DUTY
TIME OFF TO VOTE
OTHER
COMMENTS
CERTIFICATION / APPROVALS
I understand that time away from work is subject to my supervisor’s approval and college
policies.
Employee Signature: _________________________________ Date: __________________EE
CERTIFICATION
Supervisor Approval: _________________________________ Date: ___________________
Employee Engagement: _______________________________ Date: ___________________
Completed form must be returned to the Office of Employee Engagement for processing.
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