Bereavement Leave Request
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EMPLOYEE NAME
DATE
MM
/
DD
/
YYYY
SOC. SEC. NO.
DEPARTMENT
DAY
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TYPE
TOTAL DAYS
VACATION REQUEST FORM MUST BE SUBMITTED TWO WEEKS PRIOR TO VACATION. ONLY ONE WEEK MAY BE REQUESTED PER FORM. IF ADDITIONAL VACATION IS REQUESTED BEYOND ONE WEEK, USE A SECOND FORM
EMPLOYEE SIGNATURE
SUPERVISOR: SIGN AND DATE BELOW INDICATING APPROVAL GRANTED OR DENIED FOR THIS VACATION REQUEST. SUBMIT COMPLETED FORM TO PAYROLL DEPARTMENT.
SUPERVISOR SIGNATURE
APPROVAL
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REASON FOR DENIAL (IF APPLICABLE)
DATE REC’D BY PAYROLL
MM
/
DD
/
YYYY
DATE PAYROLL RECORDS UPDATED
MM
/
DD
/
YYYY
BY
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