"*" indicates required fields I, the undersigned request the following dates as Paid Time Off.Please select your date(s) and the PTO time below. List each date separately and designate the appropriate PTO for each corresponding date:Name* First Last How many days are you requesting off?*12345Requested Date* MM slash DD slash YYYY PTO Hours Requested*Requested Date* MM slash DD slash YYYY PTO Hours Requested*Requested Date* MM slash DD slash YYYY PTO Hours Requested*Requested Date* MM slash DD slash YYYY PTO Hours Requested*Requested Date* MM slash DD slash YYYY PTO Hours Requested*Total Number of PTO Hours RequestedAre you salaried or full-time hourly?* Salaried FT Hourly PT Hourly Please select the most accurate department or position for you?*ISL DepartmentNatural Home DepartmentOffice StaffDirectorDay HabClinicExecutive Director Direct ReportWhat reason best describes your request?*Personal Leave (generic)Vacation TimeFloating HolidaySupplemental Hours for Unforeseen ShortageWellness Time (4 or 8 hours)Sick TimeWhat reason best describes your request?*Personal Leave (generic)Vacation TimeWellness Time (4 or 8 hours)Supplemental Hours for Unforeseen ShortageSick TimeWhat reason best describes your request?*Personal Leave (generic)Vacation TimeWhere would you like an email confirmation of your request to be sent?* ELECTRONIC SIGNATURE:* By checking this box, you are consenting to an electronic signature that the preceding information is (1) complete and accurate and (2) was completed by the staff listed in the “Your Name” field. Falsifying information on this form is a serious offense. IP addresses and usernames are recorded with each submission.CAPTCHA
