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PTO Leave Request Form

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

  • General

  • MM slash DD slash YYYY
  • Paid Time Off

    Must be used in increments of 4 or 8 hours
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • Bereavement Leave

    Up to three days of paid leave due to a death in the immediate family is available for eligible employees
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • Jury Duty Leave

    Up to three days of paid leave for jury service is available for eligible employees
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • Unpaid Leave

  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • 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.
  • This field is for validation purposes and should be left unchanged.