Family Medical Leave (FMLA) Request Form

Name: * Required

First

Last
Employee ID: * Required
Phone: * Required
Leave requested for: * Required
- Self
- Adoption
- Other family member
How would you like us to send the FMLA Certification form?
- Emailed
- Mailed to my address
Email address: * Required
Residential address: * Required

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country