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Leave Request
REQUEST FOR LEAVE OF ABSENCE
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Initial Leave Request
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Medical Leave
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Please check the appropriate box to indicate the reason for your leave request
Medical Leave
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Health Condition (Self)
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All Medical Leave requests require a signed Medical Certification from an approved Medical Practitioner
Expected Delivery Date
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Injury Date
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Leave Start Date
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Do You Know Your Leave End Date?
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No, I don't know when my leave will end
Leave End Date
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Documentation
Max. file size: 64 MB.
Please attach any relevant Leave Request (Medical, Military, Education, Other) documentation
Insurance: Employee is responsible for arranging continuation of coverage; see the Benefits designate within your company to discuss policy and payments.
BY SIGNING THIS, I CERTIFY THAT THE INFORMATION PROVIDED IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.
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