Family Medical Leave (FMLA) Request Form

Name * Required

First

Last
Employee ID: * Required
Phone * Required
Address * Required

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country
Leave requested for: * Required
- Self
- Adoption
- Other family member
Supervisor's name: * Required

First

Last
Supervisor's email address: * Required
Reporter's email address: * Required