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Time-Off Request
Employee
*
Select Name
Amy Boche
Di Evenson
Jackie Amacci
Jamie Nelson
Jenna Becker
Joleen Kincade
Kari Mangan
Karina Henriksen-Mundo
Karla Flippo
Katie Trauger
Kristin Kelly
Lindsey Thompson
Lisa Mogensen
Michelle Schuneman
Sue Etienne
Tracy Behr
Valerie Crotty
Email
*
Start Date
*
MM slash DD slash YYYY
End Date
*
MM slash DD slash YYYY
Start Time
*
:
Hours
Minutes
AM
PM
AM/PM
TIME YOU WILL BE LEAVING OR IF FOR THE DAY PUT 8AM.
End Time
*
:
Hours
Minutes
AM
PM
AM/PM
TIME YOU WILL RETURN OR IF FOR THE DAY PUT 5PM.
How would you like to take this time off?
*
PTO
Blue Dots
Gold Coins
No Lunch
Partial Lunch
No Pay
Funeral
Other
# 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.
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