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Request for Family or Medical Leave Request for Family or Medical Leave Please Note This Form
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Request for Family or Medical Leave Request for Family or Medical Leave Please Note This Form Powered By Docstoc
					                            Request for Family or Medical Leave


Please Note:
This Form should be used to request FMLA leave involving intermittent periods of time off or a
reduced daily or weekly work schedule. An eligible employee requesting FMLA leave must give
thirty (30) days’ advance notice to their supervisor of the need to take unpaid FMLA leave when
the need for leave is foreseeable. When the need for leave is not foreseeable, such notice must
be given as soon as practicable. The use of FMLA leave will be subject to verification. The
Company may require that an employee’s request for FMLA leave to care for the employee’s
seriously ill spouse, son, daughter, or parent, or due to the employee’s own serious health
condition, be supported by a certification issued by the health care provider.

Name: ______________________________________________________

Date: ________________

Name of Department: _________________________               Title: ______________________

Status:         [   ]   Full Time    [   ]   Part Time

Date of Hire: _____________________________

Length of Service: ________________________

I am requesting family or medical leave for one or more of the following reasons:

[   ]     The birth of my child and in order to care for him or her.
Expected date of birth: __________ Actual date of birth: _________________
Leave to start: __________ Expected return date: __________
[   ]     The placement of a child with me for adoption or foster care.
Date of placement: __________
Leave to start: __________ Expected return date: __________
[   ]     To care for my spouse, child, or parent who has a serious health condition.
Leave to start: __________ Expected return date: __________
Note: A physician's certification may be required for leave due to a serious health condition.
[   ]     For a serious health condition that makes me unable to perform my job.
Describe health condition: _____________________________________________________
Leave to start: __________ Expected return date: __________
Note: A physic
				
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PARTNER William Glover
I received my B.B.A. from the University of Mississippi in 1973 and my J.D. from the University of Mississippi School of Law in 1976. I joined the firm of Wells Marble & Hurst in May 1976 as an Associate and became a Partner in 1979. While at Wells, I supervised all major real estate commercial loan transactions as well as major employment law cases. My practice also involved estate administration and general commercial law. I joined the faculty of Belhaven College, in Jackson, MS, in 1996 as Assistant Professor of Business Administration and College Attorney. While at Belhaven I taught Business Law and Business Ethics in the BBA and MBA programs; Judicial Process and Constitutional Law History for Political Science Department); and Sports Law for the Department of Sports Administration. I am now on the staff of US Legal Forms, Inc., and drafts forms, legal digests, and legal summaries. I am a LTC and was Staff Judge Advocate for the Mississippi State Guard from 2004-2008. I now serve as the Commanding Officer of the 220th MP BN at Camp McCain near Grenada, MS. I served on active duty during Hurricanes Dennis (July, 2005), Katrina (August, 2005) and Gustav in 2008. I played football at the University of Mississippi in 1969-1971 under Coach John Vaught. I am the author of the Sports Law Book (For Coaches and Administrators) and the Sports Law Handbook for Coaches and Administrators (with Legal Forms),