#6757 Request Time Off / Sick Request

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**THIS FORM NEEDS TO BE SUBMITTED BY SUNDAY END OF DAY, ANY REQUEST AFTER SUNDAY WILL BE PAID THE NEXT PAYDAY**
Submitting this form does NOT guarantee approval from Management. Please take this into consideration before making any travel arrangements or plans on your end.

Today's Date *

YYYY

What is your full name (first and last name) *

What is your job title? *

Crew Member

Shift Manager

Department Manager

Store Maintenance

How many HOURS are you requesting? (*Please note that hours requesting is based on how many hours you have available*) *

Type of leave you are requesting *

*Unpaid* Request Time Off

Paid Sick Leave

PTO (ONLY ELIGIBLE DEPARTMENT MANAGER)n 3

If you selected SICK above, please choose one of the following *

(Paid) Preventive Care* or diagnosis, care, or treatment of an existing health condition for myself or a family member

(Paid) I am a victim of domestic violence, sexual assault, stalking and seeking care, psychological counseling, shelter or support services, safety-related measures, or any relief, including restraining orders, to help ensure the health, safety, or welfare of myself or my child(ren)

(PAID) PTO-PAID TIME OFF (ONLY ELIGIBLE DEPARTMENT MANAGER)

(Paid) I would like to use my Paid Sick Leave due to Covid related symptoms

(Unpaid) I am entitled to use Paid Sick Leave for one of the reasons above but voluntarily choose not to do so. I understand that if I mark this option, I will not be paid for the time off taken at this time and can choose to take the leave accrued another time.

(Unpaid) Not Sick, requesting for Vacation or Personal Time Off

( Unpaid ) I do not want to be paid for my time out, however I am having Covid related symptoms

What are the *DATES* you're requesting? Please use this format for the accurate dates (mm/dd/yyyy). By not using the correct format your request will be automatically dismissed. *

You understand that if you do not provide the information requested on this form, your time off may be denied. You also understand that falsifying information in this form (or in any company document) may result to disciplinary action up to and including termination *

Yes, I understand

If you stated you had Covid symptoms, did you take a covid test and if so when was your test taken, and result?
*

Type your first and last name again that you agree on the above statement: *

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