Vacation Leave Form 

 
 
Employee Name  Date Filed 

Vacation Request Start Date  Return to Work date  Total Work Days Off 

Employee Signature 

Have you endorsed all of your duties and responsibilities  Yes ☐

before your VL? 
No ☐

Endorsed to: 

This Vacation Request is:  Granted ☐

Denied ☐

Reason: 

Supervisor Name and Signature:  Date 

GM's Signature  Date