Name:                                        

Sick Leave:            Type of Illness:

Full Day       Will be In Later - Time:

The following times are requested for time off:

More than one time wanted                      Yes        No

1.   through      returning on   

2.   through      returning on   

I would like the following times used:

Hours HC:                  Hours CTO:         

Hours Vacation:        Personal Holiday:   

I understand that all requests are subject to change and/or cancellation at any time and that requests are granted on a first-in basis. Docks will be applied against wages if sufficient leave credits are not available for the time off requested.