Telecommuting Application Form

Name _________________ Title _____________________

Department ________________ Supervisor __________________

Number of days I would like to telecommute: 2 or 3

Please describe how you think your job responsibilities are suited for telecommuting:

Supervisor

I have discussed the possibility of telecommuting with the above mentioned employee. I believe this employee is a good candidate based on job responsibilities and performance in his or her current position.

Supervisors Signature________________ Date ________________

TELECOMMUTING APPLICANT

I have discussed telecommuting with my supervisor and understand that my application does not guarantee that I will be eligible to telecommute. I have read the telecommuting policy and understand that it is not an entitlement and that it is not appropriate for every employee. I understand that telecommuting can be terminated at any time by {Enter Company Name} or me.

Telecommuting Applicants Signature ___________________

Date __________________

HUMAN RESOURCES

Reason:

Signature ________________ Date ______________________