(By Employee)

I, (name of employee), hereby request a vacation leave commencing (specify date) through (specify date):

I have been advised that the total number of vacation days presently accrued total (specify).

Thank you for your attention to this matter.

_____________________________
Signature of Employee

_____________________________
Printed Name of Employee

Social Security Number:

Date:

Telephone number and address where I can be located during vacation:

EMPLOYER AUTHORIZATION

Request Approved:

Request Denied: (Specify Reason)

By:

Title:

Department:

Comments: