Employee Time-Off (Vacation) Request Form
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Employee Time-Off Request Form
Today’s Date: ________________________
Employee’s Name: ________________________
Time-Off Request: _____ ☐ Days ☐ Hours
Beginning on: ________________________
Ending on: ________________________

Reason for Request
☐ - Vacation

☐ - Personal Leave

☐ - Funeral / Bereavement

☐ - Jury Duty

☐ - Family Reasons

☐ - Medical Leave

☐ - To Vote

☐ - Other: _____________________________________

I understand that this request is subject to approval by my employer.

Employee’s Signature: ________________________ Date: ___________
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Employer’s Decision
☐ - Approved ☐ - Rejected
Employer’s Signature: ________________________ Date: ____________
Print Name: ________________________