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: