Employee Name:  __________________________________________________________ Dates Requested: __________________________________________________________ Reason for Request: ________________________________________________________ ________________________________________________________ I understand I am requesting time off without pay and that I will not be compensated for this time. Employee Signature:_____________________________________________________ Date:  ____/____/____

• Approved
• Not Approved – Reason:

_________________________________________________________________________ Manager Signature: ___________________________________________________________ Date:  ____/____/____