Time Off Request | cowboyclinic

Request for Time Off

First Name

Last Name

Type of Absence Requested

Paid Time Off (PTO)

Non-Paid Time Off

Select the requested time off. (please explain below if applicable)

Full Day(s) Off

Partial Day(s) Off

Additional Info

Have you attempted to find, or have already made arraingments for coverage of your shift(s) via trading with your co-workers

Yes

Name of Co-worker agreeing to cover shift.

Date of Absence From

Date of Absence To

Available to return to work on this date.

For Partial Day time off requests list the hours requests off here. (ex. "from 12:00pm to 3:00pm)

Total Hours of PTO Requested? This will be the amount you will be reimbursed for on your paycheck.

I have read the related and applicable policy and understand that all requests are subject to approval by clinic management. Further, I acknowledge understanding that I must submit requests for absences, other than sick leave, a minimum of four weeks prior to the first day I will be absent to allow for staffing coverage.

Cowboy Clinic

&

Urgent Care LLC

Request for Time Off

Address

108 East 20th Ave.

Torrington, WY 82240

Phone: (307)-269-0947

Fax: (307)-459-6948

Contact us by email:

admin@cowboyclinicandurgentcare.com

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