LSJE, LLC 6100 Red Hook Quarters, Suite B-3, St. Thomas, VI 00802-1348 Phone: E-mail: Vacation/Leave Form Name: Cuthbert Titre Division/Department: Date Request Submitted: 12/17/18 Cell: Phone (other) E-mail: Dates of Vacation/Leave Requested: Date of Vacation/Leave to Begin: 101/02/19 Date of Return to Work 01/07/18 Number of employees in your division/department expected to be absent during your requested vacation/leave?* Total Number of Days Away: Vacation with Pay: Leave without Pay: Personal/Sick Days: Holidays: Weekend Days: Other:" 3 ■ ■ Total Days Away: I5 I "If 'Other,' please explain: Employee Signature: For internal use only: Number of vacation days permitted annually: Number of vacation days used year-to-date: Number of vacation days granted per this request: Number of vacation days remaining after this request: Number of medical days permitted annually: Number of medical days used year-to-date: Number of medical days granted per this request: Number of medical days remaining after this request: Date: Authorization: •Areas indicated must be verified with the supervisor before vacation/leave will be approved. Approval Date: EFTA01223545