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W. R. MEADOWS, INC. Vacation/Leave Request Form

This form must be used to adequately document any paid or unpaid time taken off. Information included on this form may be used to determine if the requested leave time qualifies as an entitlement under the Family Medical Leave Act. All Vacation/Leave Requests must be submitted and approved at least fifteen (15) days in advance.

Employee Name*
Employee Email*
Branch/Location*
Department*
Employee #
Date*
MM slash DD slash YYYY
I hereby request a leave from:*
MM slash DD slash YYYY
thru:*
MM slash DD slash YYYY
Type of Leave Requested*
- Vacation Day
- Sick Day
- Military Leave
- Funeral
- Leave of Absence
- Family Medical Leave
for a total of ____ working days as follows*
Please enter a number from 0.2 to 90.
for a total of ____ working days as follows*
Please enter a number from 0.5 to 90.
If half or partial day, indicate which one:
- AM
- PM
Type of Request*
- Original
- Extension
- Change
- Cancel
Paid/Unpaid*
- Paid
- Unpaid
- Advance Vacation check Requested
Note: Advanced Vacation Checks are available in one (1) week increments only and must be requested two (2) weeks prior to start of vacation.
Reason for leave (if not indicated above)
While on leave, I can be reached at (Address & Telephone)
Employee Signature (type your name)*
Date*
MM slash DD slash YYYY