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PTO Request

Complete the following form, then click on "Submit Form" to send.

Employee Name:

Month:

INDICATE IF YOU ARE FLEXING

Enter Date(s) in Box(es) Below:

SUNDAY

MONDAY

TUESDAY

WEDNESDAY

THURSDAY

FRIDAY

SATURDAY


Example:

SUN

MON

TUE

WED

THU

FRI

SAT

 

 

 

 

 

 

 

 

6
Labor Day
Off

7

8

9

10

11
Flex
Will work

 

 

 

 

 

 

 

19

20
Off

21
Off

22
Off

23
Off

24
Off

25

 

Dates of Paid Time Off:


Bereavement Leave:

Continuing Ed:

Unpaid Time Off:


NOTE: USE ONLY ONE FORM PER MONTH UP TO 60 DAYS IN ADVANCE. ALL REQUESTS MUST BE MADE ON THIS FORM.

Actual hours paid or unpaid will be adjusted according to actual PTO balance available when time off is taken.


 

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PMB# 195 6923 Maynardville Pk Knoxville, TN 37918-5324
Phone (865) 705-7128 Fax (865) 687-3123

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