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Request for Leave

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					                     EMPLOYEE REQUEST FOR LEAVE FORM

 Employee Name: ________________________________ SS #: _________________________

 Department: ______________________________ Supervisor: _________________________

 Dates of Leave:        from ____________________ to _____________________

TYPE OF LEAVE
____ Family Medical Leave

____ Extension of Family Medical Leave – 30 Days (Must be accompanied by doctor’s written note)


 REASONS Please Print Clearly

 _____________________________________________________________________________________

 _____________________________________________________________________________________

 _____________________________________________________________________________________

 _____________________________________________________________________________________

 _____________________________________________________________________________________

         Last Day Worked:               _____________________________

         Leave Effective Date:          _____________________________

         Return to Work Date:           _____________________________

 Paid Time Off To Be Used:       _____ Sick            _____ Vacation

 Request for Sick Bank Use _____ (Must meet criteria for sick bank use)


 Employee Signature: ___________________________________________ Date: _________________

          ** This Request for Leave Must be accompanied by FMLA Certification Form **


For HR use only                  ____ Leave Approved                 ____ Leave Not Approved

HR Signature: _________________________________________________ Date: __________________


                                                                                           HR 7/2012

				
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