Time Off Request Form Fields

Employee Name:

Employee #:

Time Off Start Date:
Time Off End Date:

Total Number Of Days Off Work:

Please Indicate The Type & Total Days Below:

Field Employees are Entitled to 3 unpaid Personal Days After Completion of 1 Year of Service. More Than 2 Personal Days Requires 2 Weeks Notice.

Personal Days:

Field Employees are Earn 5 Vacation Days At The Start of Their 11th Year of Service. Personal Days Are Not Available to Employees if They Have Earned Vacation. Vacation Days Require 3 Weeks Notice.

Vacation Days:

See Employee Handbook for terms and Conditions of Paid and Unpaid Funeral Leave.

Funeral Leave:

Time Off for Doctor or Dental Visits, FMLA, or any special Request Not Including Personal Days While Available to Employee.

Other Time Off:

Employee Signature & Date:
Foreman's Signature & Date:
Operation's Manager Signature:
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.