Leave Request Form

* Required Fields

SECTION ONE EMPLOYER INFORMATION
 
 Company Name *  Contact Name *
 Contact Info *    
 

SECTION TWO EMPLOYEE INFORMATION
 
First Name*          MI: 
Last Name*
Soc. Sec. Number*    Date of Birth*
Address*
City*    State*    Zip Code*
 

SECTION THREE LEAVE EVENT INFORMATION
 
 Employee Notification Date*  
 FMLA Start Date*
 Date Last Actively At Work*
 Average hours scheduled per week*

         Qualifying Event*

 

SECTION FOUR PLAN INFORMATION
  HOURS USED
   How many hours has the employee used for FMLA this year?
 
  Date Of Hire and Hours Worked
   Employee Date Of Hire
 
   Total Hours Worked in Past Year
 

Notes: