Time-Off Request

Employee*
Email*
Start Date*
MM slash DD slash YYYY
End Date*
MM slash DD slash YYYY
Start Time*

:

AM/PM

TIME YOU WILL BE LEAVING OR IF FOR THE DAY PUT 8AM.
End Time*

:

AM/PM

TIME YOU WILL RETURN OR IF FOR THE DAY PUT 5PM.
How would you like to take this time off?*
# of Hours Requested*
Will you be taking lunch?*
- Yes
- No
Comments:
E-Signature
Your Electronic Signature is valid for Paid Time-Off Requests Only.
E-Signature*
I Acknowledge and Agree to the Terms & Conditions of the Paid Time-Off Agreement
I understand and agree that Blue Ribbon has agreed to advance me personal time-off, which I will be paid for and currently may not have accrued, for the time period requested on this form. I further understand and agree that I must reimburse Blue Ribbon for the personal time-off I have been paid for, but not yet earned, by either deducting paid time-off that I accrue or, in the event that my employment relationship with Blue Ribbon is terminated, for any reason, prior to my accruing the requisite paid time-off for reimbursement, I authorize Blue Ribbon to deduct any and all remaining unreimbursed paid time-off from my final payroll payment.

E-Signature