APL REQUEST FORM

Form for employees to request APL.

Today's Date:

Position in Agency:(Required)

Please use dropdown to choose position

Your Name:(Required)

First Last

APL Request:(Required)

APL Request- Two week notice

APL Request- Less than two week notice

Please check the box that describes the APL Request

Direct Supervisor/Manager (Pick from dropdown menu):

First Day of APL:(Required)

Last Day of APL:(Required)

Date I will RETURN to work:(Required)

Total Number of Hours Requested:(Required)

Total Number of Days Requested:

Explanation: (Not Requred)

List shifts that need covered by: Date – Consumer Name – Scheduled Shift(Required)

Example: 5/22/23 – Bob Smith – 7am-7pm

Signature(Required)

CAPTCHA