Please complete all sections of this form. The Center Director, Assistant Director and/or Executive Director reserve the right to review and give final approval of the request. Requests for the same dates as other employees’ requests will be reviewed by the executive director and generally granted based on the date the request is submitted. Date Submitted Name Title Title - None -MissMsMrMrsDrOther… Enter other… First Last Personal Email Address Center/Program/Office Days and Dates Requested (List the weekday/s and date/s below) Select Pay Code: Vacation Personal/Sick Meeting/Training Off Site Work Time Bereavement Jury Duty Leave Without Pay Number of Hours If Dividing hours between two pay codes, select second option below: (example 5 hours Vacation and 5 hours Personal) Vacation Personal/Sick Meeting/Training Off Site Work Time Holiday Bereavement Jury Duty Snow Day Number of Hours Reason for Request (May be omitted, if request is for personal time) I have discussed this with my Center Director and received their approvalSend To leadctrdir@mledp.org leadctrdir@mledp.org exdir@mledp.org exdir@mledp.org Leave this field blank