Paid Time Off Request Form

Todays Date

Name

First

Last

Email Address

Last 4 of SS Number

Company name of your current assignment

ACCU Job Center that dispatched you

Request time off FROM

Request time off TO

Total hours requested

Additional Comments

Check to confirm that you have read this statement:

I understand that in NJ and DE I must work a minimum of 120 days (4 months) and in PA a minimum of 90 days (3 months) to qualify for sick time, and I may not use more than 40 hours in one calendar year. I also understand that I cannot have a lapse in employment longer than 6 months to qualify for sick time.

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