EMPLOYEE PTO REQUEST FORM

Must be sent to office no later than the Monday of requested leave.

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General

Name*

Paid Time Off

Must be used in increments of 4 or 8 hours

Bereavement Leave

Up to three days of paid leave due to a death in the immediate family is available for eligible employees

Jury Duty Leave

Up to three days of paid leave for jury service is available for eligible employees

Unpaid Leave

Verification

This form should not be used to request leave under the Family and Medical Leave Act (FMLA) or to request leave as an accommodation under the Americans with Disabilities Act (ADA). Employees should consult with HR to request leave under the FMLA or ADA.
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