Days Off Without Pay

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:  ____/____/____