FMLA & Military Leave Request Form

FMLA & Military Leave Request Form
Full Legal Name*

First NameLast Name
CPR Email Address*
example@example.com
What was your hire date?*

MonthDayYear
Date
Are you full-time or part-time?*

Full-time benefit eligible (35+ hours)Part-time benefit eligible (30-34 hours)Part-time not benefit eligible (29 hours or less)
What is your expected FMLA start date?*

MonthDayYear
Date
Why are you going out on leave?*
What is the type of FMLA leave you intend to use?*
Please provide a copy of your current military orders.*

This is required to submit your FMLA for approval.
Cancelof
Do you have PTO?*

YesNo
How many hours?*
Your FMLA submission is confidential. The health information included will not be viewed by anyone other than HR; however, your supervisor will be notified of the leave request.
Supervisor's Full Legal Name*

First NameLast Name
Supervisor's CPR Email*
example@example.com
Should be Empty:

Your FMLA submission is confidential. The health information included will not be viewed by anyone other than HR; however, your supervisor will be notified of the leave request.