Paid Time Off During Leave Request Form
Submit this Paid Time Off During Leave Request Form to request additional paid time off while you are currently on leave. Please complete all fields for efficient processing.
Full Name
*
First Name
Last Name
Employee Email Address
*
example@example.com
Department
*
Please Select
Human Resources
Finance
Operations
Sales
Marketing
Engineering
Other
Current Leave Type
*
Please Select
Medical Leave
Parental Leave
Personal Leave
Sabbatical
Other
Current Leave Start Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Current Leave End Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Requested Paid Time Off Start Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Requested Paid Time Off End Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for Paid Time Off Request
*
Supervisor or Manager Name
*
Submit Request
Should be Empty: