Time Off Request
Please submit the times you request to take off work and the type of leave you are taking.
Professional Name (First, MI, Last) *
Enter the last 4 numbers of your SS# *
Type of leave requested *
Comments or Reason for leave
The first day you request to be off: *
MM
/
DD
/
YYYY
The last day you plan to be off: *
MM
/
DD
/
YYYY
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