Night Work Opt-Out Form
Submit this form to formally opt out of assigned night work duties.
Full Name
*
First Name
Last Name
Employee ID
*
Department
*
Please Select
Operations
Customer Service
IT
Logistics
Administration
Other
Job Title
*
Supervisor/Manager Name
*
Work Schedule (Current)
*
Opt-Out Effective Start Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Opt-Out End Date (if applicable)
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for Opting Out of Night Work
*
Signature
*
Submit Opt-Out
Submit Opt-Out
Should be Empty: