Leave of Absence Request Form

Company Name*

Full Employee Name*

Preferred Pronouns

Your Home Address*

Street address, City, State, Zip Code

Your Worksite Location & State*

Indicate if you work remotely

Your Regular Workdays*

Your Regular Work Hours*

Your Personal Phone Number*

Area CodePhone Number

Your Personal Email Address*

example@example.com

Your Preferred Contact Method*

Your Temporary Contact Address

e.g., temporary residence while caring for a family member

Leave Start Date*

Date

Estimate Leave End Date

Date

Please select what leave frequency you are requesting*

Is your employer aware of your Leave request?*

Will you use accrued Paid Time Off (PTO) while on leave?*

If yes, please specify dates and number of hours used each day.

Leave Type(s) (Check all that apply)*

FMLA is federal law. Eligibility: Must work for a covered employer, be employed for at least 12 months, worked a minimum of 1,250 hours during the 12-months immediately preceding the start of leave, and work at a worksite location with 50 or more employees within a 75-mile radius.

State Name*

Will you be applying for state wage replacement?*

Leave Reason(s): Medical certification may be required. Please check all that apply.*

Bonding Leave: the birth, adoption, or foster care of your child within 12 months following birth or placement of the child;Family Care Leave: to care for a covered family member (based on leave type) with a serious health condition;Your own Serious Health Condition: The inability to work because of a serious health condition; Includes medical conditions related to pregnancy and childbirth.Military Emergency Leave: a “qualifying exigency,” as defined under the FMLA or other state- mandated leave, for military operations arising out of a covered family member’s active duty or call to active duty as a member of the military reserves or National Guard in support of a “contingency operation” declared by the U.S. Secretary of Defense, President, or Congress, as required by law;Military Caregiver Leave: to care for a covered family member, (as defined in the applicable law), who is a member of the Armed Forces (including military reserves and National Guard) undergoing medical treatment, recuperation, or therapy, is in an outpatient status, or is otherwise on the temporary disability retired list- with a serious injury or illness incurred in the line of duty while on active duty that may render the individual medically unfit to perform his or her military duties.

Signature