Time Off / Vacation Pay Request Form Date _______________ ________
Last Name: _______________ First Name: __ _______________ Employee # _________
Site Name/Address: _______________________________________________________________________________
_
Home Address: _____________________________________________________ Postal Code: ___________
Home Phone # _____________________________ Work Phone # _________________________
Type of time off requested (please check one):
Leave of Absence Receiving Benefits Vacation Personal time Appointment
Dates for Time Off (MM/DD/YY)
First Day Off Last Day Off First Day Returning to Work
Reason for time off (please provide details) ____ __________________
________________________________________________________________________________________
VACATION PAY REQUEST
Will you require vacation pay to be paid out during this time off? Yes No
If yes, will the vacation pay required be for the full amount earned or partial amount to cover the wages you would have earned during
this time off? Full amount (indicate pay date needed by) __________________
OR Cover normal wages during time off
Please note
Requests for vacation time of one (1) week or more shall be made in writing at least four weeks in advance of the start of the
vacation. For requests of two (2) consecutive days but less than one (1) week, two (2) weeks’ notice must be provided. For
requests of one (1) day, one (1) week notice must be provided. Provided notice is given, vacation pay shall be paid on the day
immediately preceding the start of the employee’s vacation, if requested by the employee.
Subject to the written request for vacation, the Employer shall grant in writing the vacation request within five (5) working days,
the vacation request will be deemed to be granted. Once approved, no vacation will be changed without mutual consent of the
Parties.
Employee Signature _______________________________
OFFICE USE Date Received: ______________________
Request approved Request denied Signature: ________________ Date:
Reason request denied: ____________________________________________________________________
Scheduling ______ Payroll ______ Branch Operations _____
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