Flexible Schedule Work Request Form

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Department:

Supervisor:

Date:

This is a formal request for a flexible work schedule of the type indicated below:

FLEX TIME (Type)
Fixed starting and quitting times
Fixed varied starting and quitting times
Compressed work schedule

Description of the flexible work schedule requested, indicating actual hours and times I would like to work:
(Example: 10:30a-6:30p)

Supervisor Signature Approved:
Date:

Supervisor Signature Disapproved:
Date: