This form is to be used for a school district to request additional time within a school year.

I request additional time from the following individual:

TCESC Employee Name:

Title: Department & Program:

Additional time requested:

Total Days:	Total Hours:

Actual Work Dates:

TCESC employee must submit a revised calendar with this form.

I understand that our district will be billed for this additional time beyond the employee’s contract year.

District Name:

District Superintendent’s Signature:____________________________Date:__________

District Treasurer’s Signature:_________________________________Date:__________

TCESC Supervisor Signature:_________________________________Date:__________

TCESC Director Signature:___________________________________Date:__________

TCESC Superintendent Signature: _____________________________Date:__________

TCESC Treasurer Signature: _________________________________Date:__________

Cc: human resources, supervisor, director, treasurer, district

Revised: 6/8/04

Request for

Extended Services

Trumbull County

Educational

Service Center

Valued Gateway Client

2004-06-08

lubichpa

TCESC