Leave of Absence Request

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.

Employee Information

First and Last Name(Required)

Job Title(Required)

Supervisor's Name(Required)

Home Phone(Required)

Home Address(Required)

Email Address(Required)

Reason for Requesting Leave

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

My own serious health condition.

To take care of family member with serious health condition.

Birth of my child: to take care of my newborn child.

Qualifying exigency because a family member is on or has been called to covered active duty in regular armed forces to a foreign country.

Duration of Leave

Date leave is expected to begin(Required)

Date leave is expected to end(Required)

Employee Certification

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

Yes, I certify that the above information is true and correct to the best of my knowledge:.