Furlough Week Request Form

FURLOUGH WEEK REQUEST FORM

DATE

Employee Identification Number

LAST NAME FIRST

POSITION/DEPARTMENT IMMEDIATE SUPERVISOR

PERSON WHO WILL BE RESPONSIBLE FOR YOUR DUTIES:

I REQUEST FURLOUGH ON:

Month:

Year:

HOURS REQUESTED:

XXX / FURLOUGH

TYPE OF LEAVE:

I UNDERSTAND THAT I WILL NOT RECEIVE PAY FOR THIS FURLOUGH TIME. MY PAY WILL BE REDUCED ON THE PAYCHECK THAT COVERS THE FULOUGH TIME. TO COMPLY WITH FEDERAL AND STATE LABOR LAWS, A FURLOUGHED EMPLOYEE MUST STRICTLY OBSERVE A NO-WORK RULE THAT INCLUDES NOT READING OR RESPONDING TO E-MAILS AND NOT CALLING OR RESPONDING TO CALLS FROM COLLEAGUES.

______

EMPLOYEE SIGNATURE DATE

APPROVED DISAPPROVED ______

IMMEDIATE SUPERVISOR DATE

APPROVED DISAPPROVED ______

VICE PRESIDENT DATE

Revised 08/07/2009gc/tl