LSJ Employees, LLC Mailing Address General contact information Tel: E-mail: Accounts payable department contact information St. Thomas. VI 00802-1348 Fax: Name: Date of Request Vacation / Leave Form Thomas J Melnick 5/11/12 Dates of Requested: Date of First Day of Vacation: Total Number of Days: Leave Days: 16 June 8th 2012 Weekend Days: 8 Holidays: Date Return to Work: Personal / Sick: Type of Leave: 07 Vacation with Pay C' Leave without pay r Personal Sick Leave r Other If Other Explain: July 2nd 2012 Days Remaing: 0 days List of all contact information: Phone: Cell: Email: The following must be verified with Estate Manager 1. The number of vacation days you have taken. 2. The number employee in your division / department that are leave at the same time Approved: EFTA00593602