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Fill and Sign the Paid Time off Request Form Requestor Name De

Fill and Sign the Paid Time off Request Form Requestor Name De

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TIME-OFF REQUEST FORM Fill in "Employee Section" and return to your Supervisor. Requests should be made at least two (2) weeks prior to the date of absence, whenever possible. . EMPLOYEE SECTION : Employee's Name: ____________________________________________________________________________________ First Name - Please Print Last Name - Please Print Absence Information: Dates of absence from work: Starting On..................: _ _ / _ _ / _ _; mm dd I will return to work on: _ _ / _ _ / _ _; mm dd Departure Time (Only enter for partial days.).....: _ _ : _ _ am / pm yy circle one Return Time(Only enter for partial days.)...........: _ _ : _ _ am / pm yy circle one I am requesting time off for the following reason:  Jury Duty  Military Leave  Medical Leave (Short Term Disability)  Family Medical Leave Act (FMLA) (Official application forms are needed - See HR Dep't.) __ for the birth and care of the newborn child of the employee __ for placement with the employee of a son/daughter for adoption/foster care __ to care for an immediate family member (spouse, child, or parent) with a serious health condition __ to take medical leave when the employee is unable to work because of a serious health condition  Personal Leave __________________________________________________________________________________ Explain reason for absence of three days or more for personal reasons. ! Personal Emergency: I hereby certify that I missed work time on the above dates due to a personal emergency and the nature & circumstance of my personal emergency was: __________________________________________________ _______________________________________________________________________________________________  Funeral/Bereavement _____________________________________________________________________________ Explain relationship to deceased.  Subpoenaed Court Appearance _____________________________________________________________________ Explain court case.  Other __________________________________________________________________________________________ Explain. I would like my time-off to be:  PAID (Deduct from my "PTO", if eligible)  UNPAID (Deduct from my "UTO", if eligible). • I understand that if my absence does not meet the criteria for an "Excused Absence" (as outlined in the Company Handbook) my absence will be subject to attendance points (even if "scheduling approval" is obtained from my Foreman). • I understand that if I'm not eligible for PTO, or if I've used up all my PTO, my absence will be UNPAID. • I understand that I'm required to reserve PTO days to cover pay for "Company-Scheduled Plant-Closed Days". _______________________________________________________________________________________________ Date: _ _ / _ _ / _ _ Employee Signature mm . MANAGEMENT SECTION (Scheduling approval - based on work-load & staffing considerations.) dd yy 0  Approved  Must Reschedule; Supervisor's Signature: ____________________________________________________  Approved  Must Reschedule; Foreman's Signature (required): _____________________________________________ Remarks: ____________________________________________________________________________________________ ____________________________________________________________________________________________________ Forward this form to the Human Resources Department. "PTO" = Paid-Time-Off | "UTO" = Unpaid-Time-Off C:\1_S_&_P\ML25513(HR & Payroll)\ml25513h1a2.doc | Revised: 27APR12 | Page 1 of 1

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