REQUEST FOR TIME OFF

Complete Steps 1 thru 7 below and fax to 610-667-2025 or toll free at

866-204-8764

1) Name:

2) Dates requesting off:

3) Employee Signature

4) Date

****************************************************************************************************

5) Supervisor Signature 6) Print Name

7) Date

For office use only

Flex Available? Y/N

Approved by

Date