I, _________________________________________________________________, hereby request a leave for FMLA. Please print name Effective date of leave:_____/_____/_____ I plan on returning to work on _____/_____/_____

QUALIFYING REASONS FOR LEAVE (please check reason for request)

The company will allow eligible employees to take Family Medical Leave for the following qualifying reasons:

• pregnancy or the birth of a child;
• the placement of a child with the employee for adoption or foster care;
• the serious illness* of the employee’s child, stepchild, or ward who lives with the        employee, foster child, parent, or spouse,   or the employee’s own serious illness.

The definition of a “Serious health condition”  includes, but […]