Attendant PTO Request Form

Attendant Name(Required)

First Last

Today's Date(Required)

Requested Days of PTO

Date of Shift(Required)

Number of Hours Requested(Required)

Please enter a number from 1 to 12.

Do you have additional days to request off?(Required)

Yes

No

Date of Shift #2(Required)

Number of Hours Requested #2(Required)

Please enter a number from 1 to 12.

Date of Shift #3

Number of Hours Requested #3

Please enter a number from 1 to 12.

Date of Shift #4

Number of Hours Requested #4

Please enter a number from 1 to 12.

Date of Shift #5

Number of Hours Requested #5

Please enter a number from 1 to 12.

Consumers and Shifts Affected by PTO (If Known)

1432 Wilkins Rd. | Erie, PA 16505

Office hours: 8:30 AM to 4:30 PM Monday through Friday

VOICES FOR INDEPENDENCE DOES NOT DISCRIMINATE IN THEIR HIRING PRACTICE; ON THE BASIS OF RACE, CREED, COLOR, ETHNICITY, NATIONAL ORIGIN, RELIGION, SEX, SEXUAL ORIENTATION, GENDER EXPRESSION, AGE, HEIGHT, WEIGHT, PHYSICAL OR MENTAL ABILITY, VETERAN STATUS, MILITARY OBLIGATIONS, oR MARITAL STATUS.