Store
Services Group
District
5
Today’s
Date:________________
Complete the following information when you are requesting time off, vacation time, sick pay, or missed days from work.
Name:___________________________
Employee Number:______________________
Days
requested off: (Dates):_______________________________________
Vacation
request must be submitted to the District Manager three weeks before your
requested time off.
DM
approval:_________________ Date: _________________
Days
off due to illness: The days you “missed” due to illness or personal
problems.
( Personal problems
include but not limited to: car accident, funerals, court appointment, dog ate
your alarm clock, etc) If you don’t go to work on the day you are assigned, I
need this form filled out. Even if you called me or sent an email.)
(Dates):______________________________________
DM
approval: __________________Date__________
I
missed work: (Dates)______________________________________
Reason
for missing work: ___________________________________
I
have checked my eligibility and I have ________hours available to me for sick
time.
(It
is your responsibility to check on your available vacation and sick time.)
I
have checked my eligibility and I have _________hours available for vacation.
(
Sick time may not be used for vacation. After three days you must submit a
Doctors permission to return to work. Read the Co. Handbook for the specifics on
this issue.)
Miscellaneous
request: Explain the situation:
DM
Approval: __________________ Date: ______________