PTO FORM

Important - Please Read:

By submitting this form, you are notifying Human Resources and the Office Manager, only, of your PTO request. In addition to submitting this form, you must notify your supervisor(s) separately of any and all time you schedule out of the office.

Name *

Name

First Name

Last Name

Office *

Please Check One: *

Unscheduled PTO (Call Out)

Scheduled PTO (Requested in Advance)

Floating Holiday

Bereavement (Please indicate relationship in additional comments below)

Jury Duty (Please provide court notice to Office Manager or Human Resources Administrator)

Date 1

MM

DD

YYYY

Date 2

MM

DD

YYYY

Date 3

MM

DD

YYYY

Date 4

MM

DD

YYYY

Date 5

MM

DD

YYYY

Comments (Optional)

Please DO NOT include personal details or medical information. If further explanation is needed, we will contact you.