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Eligible employees are entitled under the Family and Medical Leave Act (FMLA) to take up to 12-weeks of job-protected leave for certain family and medical reasons. In addition, some states have additional leave laws in which HR will check for eligibility.

Submit this request form at least 30 days before the leave is to begin, when possible.

 When 30 days’ advance submission of the request form is not possible, submit the request as soon as possible. Our Company reserves the right to deny or postpone leave if you do not give adequate notice when permitted under federal and/or state law.

Leave of Absence Request

Employee Information

Reason for Requesting Leave

I am requesting family/medical leave for the following reasons (check all that apply):(Required)

Duration of Leave

Employee Certification

By checking this box, I certify that the above information is true and correct to the best of my knowledge.(Required)