Time Off Request

Use this form to request any time off from your job

1. The staff member:

  • Completes the top section of this form
  • Submits it to his/her employer at earliest possible date (minimum two weeks)

2. The supervisor:

  • Verifies that the staff member is eligible for time off
  • Completes the bottom of form

NOTE: Understand that filling out this form is simply a request for this day off, and is not a guarantee of the day off without authorization from the employer. It is only guaranteed after the form has been signed and returned to employee. The request may or may not be granted and all requests will be handled on a first come first served basis.

Shelton Dental Center