Employee First Name: *

Employee Last Name *

Employee Contact Phone Number: *

Address

Street Address

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Employee Contact Email:

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Signing below confirms you agree to the following:

Requests take upto 72 hours to process. Filling out this form does not guarantee you request will be approved or denied. Department Directors will be notified of all requests. Some requests are pending further approval. Time off must be communicated with your supervisor, failure to do so may result in a denial of time off request.

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