Time Off Request Form

we need two weeks’ notice in order to approve the time requested.

First Name:

Last Name:

Date of absence

Date(s) you will need to be off work:

I need leave for

Submission Date:

Start Date

End Date

If you only need to be off a portion of the day, please list the time you are available to start and finish working. Available to work from

Start Time

End Time

Reason:

Doctor’s Appointment

Court Appointment (need documentation)

Jury Duty (need documentation)

Bereavement

Paid Time Off (PTO)

Unpaid Time Off (UTO)

Sick or Sick Child/Family Member

Immigration Appointment (need documentation)

Notes/Comments/Explanation:

If you need more than three weeks out you should make a written request with 4 weeks’ notice with the date of leave and return to work. We need enough time since we have to assign a different person to you to know your route and customer’s needs. This also may affect your route and/or position upon your return.

Time Off Request Form

Providing top-quality, affordable residential cleaning services throughout Northern Virginia.