LSJ, LLC 6100 Red Hook Quarters Suite 8-3 St. Thomas, VI 00802-1348 Tel: 340-7754100 Fax: 340-775-8108 E-mail: Vacation / Leave Form Name: Date of Request: 5/26/10 Dates of Requested: Date of First Day of Vacation: Total Number of Days: Leave Days: 3 Type of Leave: June 7, 14, 21, 28 Weekend Days: Holidays: 61 Vacation with Pay Leave without pay If Other Explain: 1 Date Return to Work Personal / Sick : Personal Sick Leave Other June 8, 15, 22, 29 Days &maw: 48 Days Holiday - New Years 2010 List of all contact information: Phone: Cell: Email: I 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: EFTA00730610