Essential Services Employee Authorization Form
Use this form to request and record essential-services work authorization details. Complete all required fields accurately.
Employee Details
Full Name
*
First Name
Last Name
Job Title / Role
*
Department / Team
*
Work Location / Site
*
Authorization Request Details
Authorization effective date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Authorization end date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for authorization
*
Type of authorization needed
*
Please Select
Access
Schedule adjustment
Travel approval
Site entry
Other essential-work authorization
Supervisor Approval
Supervisor or Manager Name
*
First Name
Last Name
Approval Acknowledgment
*
I confirm the employee is requesting approval for the essential-services work authorization described above.
Submit Authorization
Should be Empty: