Flexible Work Arrangement Application

Employee Name

Employee Number

Job Title

Department

Type of Arrangement Requested

                        [   ]       Flex Time

            [   ]       Reduced Hours

                        [   ]       Job Share

            [   ]       Other ______________________

                        [   ]       Part Time

Reason for Request

Work Schedule Requested

Days Requested

Hours Requested

Requested Start Date

Requested End Date

Telecommuting Information

Office Location

Office Phone Number

(       )

Voice Mail Available

[   ]  Yes  [   ]  No

Office Fax Number

(       )

Email Address

Manager Comments

Signatures and Approval

Employee

Date

Supervisor

Date

Manager

Date

Human Resources

Date