Work From Home Request Form

[COMPANY NAME]
WORK FROM HOME REQUEST

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Submit at least 1 day in advance, except in an emergency.

Employee:        [Name]          Employee number: [Number]
Department:      [Department]          Manager: [Manager]

REQUEST
From:            [Start date]     To: [End date]
Number of days:  [Days]
Working from:    [City and state]
Reason:          [Reason]

For a request longer than 30 days, or from a different state:

Note that working from another state for an extended period can create professional
tax and other state-level obligations. Human resources will confirm before approval.

CONFIRMATION BY THE EMPLOYEE
I confirm that:

   [ ] I will be reachable and available during core hours
   [ ] I have a suitable workspace and a reliable internet connection
   [ ] I can take confidential calls without being overheard
   [ ] I will follow the information security policy — device locked, no shared
       devices, no confidential work in a public place
   [ ] My commitments for this period are agreed with my manager

COVER ARRANGEMENTS
Anything that needs someone physically present, and who is covering it:

Employee
Name: [Name]
Signature: [Signature]          Date: [Date]

Manager approval
Name: [Name]
Signature: [Signature]          Date: [Date]

Human resources
Name: [Name]
Signature: [Signature]          Date: [Date]