Rockcliff Management Services

PTO/Time Off Request Form

Name:        ___________________                  

Amount of time requested:

________ # of days (8 hours)                         ________ # of hours

Date(s) out of office:  ________________________

Date of return to work:   ________________________

¨ PTO                                          TIME OFF

Reason for Request:

- Vacation                    - Personal Leave        - Funeral/Bereavement

- Jury Duty                   - Medical Leave         - To Vote 

- Other: _____________________________

I understand that this request is contingent on staff availability and subject to approval by my employer.

_____________________________________      _____________

Employee Signature                                                            Date Submitted

Employer Decision

- Approved                              Other Employees Out: ___________________

- Rejected                                PTO Balance:  __________ on date requested.

__________________________________________       ___________________

Employer Signature                                                                        Date

Notify:         - Misty Wortelboer

HR/Payroll Notes: