Please complete a copy of this form for each FMLA-qualifying leave of more than (3) days or each FMLA qualifying leave. Employee name:  ______________________________________ Date: _____/_____/_____                                                     Please print Leave is for:   Employee     To care for a family member If the request is for a family member, state relationship: _____________________________ Check all true statements:  The employee has been employed for at least 12 months (does not have to be consecutive)  The employee has worked at least 1,250 hours in the 12-month period immediately preceding the date of leave.  The employee works in a position that requires at least 1,250 hours in a 12 […]