LSJE, LLC 6100 Red Hook Quarters, Suite B-3, St. Thomas, VI 00802-1348 Phone: E-mail: Vacation/Leave Form Name: 'Gerry Anthony Titre Division/Department: Date Request Submitted: I Maintenance/RO 01/09/19 Cell: Phone (other): E-mail: Dates of Vacation/Leave Requested: Date of Vacation/Leave to Begin: 102/21/19 Date of Return to Work 03/11/19 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:" 12 0 0 0 0 Total Days Away: 118 I "If 'Other,' please explain: Employee Signature: 0 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 wilt be approved. Approval Date: EFTA01223548