[Company Name]

Absence Request

Absence Information

Employee Name:
Employee Number:
Department:
Manager:

Type of Absence Requested:
Sick	Vacation	Bereavement	Time Off Without Pay
Military	Jury Duty	Maternity/Paternity	Other

Dates of Absence: From:	To:

Reason for Absence:
You must submit requests for absences, other than sick leave, two days prior to the first day you will be absent.

Employee Signature	Date

Manager Approval

Approved
Rejected

Comments:

Manager Signature	Date