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Pto/Cme Request Form: Employee Information

This document is a PTO request form for an employee to submit to their supervisor. The form collects the employee's name, department, dates of PTO requested listed by day for each pay period, total hours and days requested, and requires the employee's signature acknowledging PTO approval depends on department staffing needs. The supervisor must then sign and date the form with optional space for comments.

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Nicholas Lerias
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© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
28 views

Pto/Cme Request Form: Employee Information

This document is a PTO request form for an employee to submit to their supervisor. The form collects the employee's name, department, dates of PTO requested listed by day for each pay period, total hours and days requested, and requires the employee's signature acknowledging PTO approval depends on department staffing needs. The supervisor must then sign and date the form with optional space for comments.

Uploaded by

Nicholas Lerias
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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PTO/CME REQUEST FORM

EMPLOYEE INFORMATION

Name: _____________________________________ Date: ________________

Dept: ________________

Supervisor’s Name: _____________________________________________________

Dates Requested: (Please note each day per pay period)

Start: __________, __________, __________, __________, __________

End: __________, __________, __________, __________, __________

Total number of hours (non-exempt only): ___________

Total number of days: _____________

I acknowledge that submittal of PTO request does not guarantee approval. PTO
will be approved by the department manager based on staffing needs of the
department.

EMPLOYEE SIGNATURE: _________________________ Date: ______________

COMMENTS:

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

Supervisor’s signature: ____________________________ Date: _________________

PTO request form


Revised 01/10/17

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