Flexible Work Arrangement Application
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Employee Name
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Employee Number
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Job Title
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Department
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Type
of Arrangement Requested
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[ ] Flex
Time
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[ ] Reduced Hours
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[ ] Job
Share
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[ ] Other ______________________
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[ ] Part
Time
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Reason
for Request
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Work
Schedule Requested
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Days Requested
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Hours Requested
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Requested Start Date
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Requested End Date
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Telecommuting
Information
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Office Location
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Office Phone Number
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( )
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Voice Mail Available
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[ ] Yes
[ ] No
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Office Fax Number
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( )
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Email Address
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Manager Comments
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Signatures
and Approval
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Employee
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Date
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Supervisor
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Date
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Manager
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Date
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Human Resources
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Date
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SOURCE:
hrVillage.com Human Resources Human Resources
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