Fill and Sign the Time Request Download Form

Flextime Request To be filled out by the Employee Requesting Flextime Date:       Employee’s Name:       Supervisor’s Name:       I       am requesting a flextime schedule with my (Print Name) job as       beginning on       . (Job Title) (Date) Potential impact of my flextime schedule on my work responsibilities and/or my department may include the following (e.g., impact on operations/work flow, potential advantages, potential disadvantages): The schedule I would desire for flextime is:                               My expectations for supervision while on flextime are :                               With my supervisor’s approval, I would like to review my flextime agreement in       months to determine its effectiveness and impact (if any) on my job performance. Thank you for your consideration (Employee’s Signature)