Vacation Request

Date: ___/___/_____

Employee Name: _______________________________________________________________________________

Department: ___________________________________________________________________________________

Supervisor’s Name: _____________________________________________________________________________

Hire Date: ___/___/_____

Vacation Earned:

[___] Employed One Year…Results in one week (five work days) of paid vacation.

[___] Employed Two Years…Results in two weeks (ten work days) of paid vacation.

[___] Employed Three or more years…Results in three weeks (fifteen work days) of paid vacation.

Dates of Vacation: ___/___/_____ to ___/___/_____

Previous number of days taken: _________________

Number of days for this request: ________________

Balance of vacation remaining: __________________

Employee’s Signature: _________________________________________________________ Date: ___/___/_____

Supervisor’s Signature: ________________________________________________________ Date: ___/___/_____

Manager’s Approval:

[___] Approved

[___] Rejected

Notes: ________________________________________________________________________________________

_____________________________________________________________________________________________

Manager’s Signature: __________________________________________________________ Date: ___/___/_____