APPLICATION FOR LEAVE FAMILY AND MEDICAL LEAVE ACT
Employee Name: ___________________________
Position: ___________________________
Send notices to me at: ____________________________________________________
FMLA Leave Requested From ___________________
To ___________________
If leave is requested on an intermittent or reduced leave schedule, describe the requested leave schedule: ________________________________________________ ______________________________________________________________________.
Reason for Leave Request (check and complete as appropriate):
1. ____ For birth of a son or daughter, and to care for the newborn child.
2. ____ For placement with the employee of a son or daughter for adoption or foster care.
3. ____ To care for the employee’s spouse, son or daughter, or parent with a serious health condition.
Name of family member: ______________________________________________ Describe reason employee needs to provide the care and the nature of the care: _________________________________________________________________.
4. ____ Because of a serious health condition that makes the employee unable to perform the functions of the employee’s job.
Briefly describe condition and job functions that employee is unable to perform: __________________________________________________________________ _________________________________________________________________.
5. ____ Because of a qualifying exigency arising out of the fact that the employee’s spouse, son or daughter, or parent is a covered military member on active duty (or has been notified of an impending call or order to active duty) in support of a contingency operation.
Name and relationship of family member: ________________________________
Describe the qualifying exigency: _______________________________________ _________________________________________________________________.
6. ____ To care for a covered service member with a serious injury or illness if the employee is the spouse, son, daughter, parent, or next of kin of the service member.
Name and relationship of family member: ________________________________
Describe reason employee needs to provide the care and the nature of the care: _________________________________________________________________.
I certify that the above information given by me is correct and that I have read the foregoing and understand my rights under the FMLA.
__________________________ ________________________ Employee’s Signature
Date
________________________________
