Axcelis PTO/Sick Time Off Request

The Axcelis employee MUST complete, sign and return this “PTO/Sick Time Off Request” form in order to be paid for sick leave or PTO.

"*" indicates required fields

Please Indicate*

PTO

Sick Time

First Name*

Last Name*

I attest that I used earned sick time for the authorized reason(s) checked below:*

to care for my child, spouse, parent, or parent of my spouse, who is suffering from a physical or mental illness, injury, or medical condition that requires home care, professional medical diagnosis or care, or preventative medical care;

to care for my own physical or mental illness, injury or medical condition that requires home care, professional medical diagnosis or care, or preventative medical care;

to attend a routine medical appointment or a routine medical appointment for my child, spouse, parent or parent of my spouse;

to address the psychological, physical, or legal effect of domestic violence; or

to travel to and from an appointment, a pharmacy, or other location related to the purpose for which the time was taken.

For PTO please provide manager approval:

Direct Supervisor Name*

Direct Supervisor Signature

Please provide the dates of your time off

Date

Number of Hours Taken

Date

Number of Hours Taken

Date

Number of Hours Taken

Date

Number of Hours Taken

Date

Number of Hours Taken

Date

Number of Hours Taken

Signature

First Name*

Last Name*

Date

Signature*

Axcelis PTO/Sick Time Off Request

For PTO please provide manager approval:

Please provide the dates of your time off

Signature

Contact Info

Employers

Job Seekers

Links

Axcelis PTO/Sick Time Off Request

For PTO please provide manager approval:

Please provide the dates of your time off

Signature

Contact Info

Employers

Job Seekers

Links

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