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Summary: Request for
Family Leave or Leave of Absence
Date:
YYYY-MM-DD
Name: Employee #:
Department:
The above-noted employee has requested the following a leave from to (inclusive)
YYYY-MM-DD YYYY-MM-DD
Family Leaves
Maternity leave with pay Parental leave with pay
Maternity leave without pay Parental leave without pay
Leave of Absence without Pay
Leave of Absence without pay Benefits Supported
Benefits Non-Supported
Other Leaves
Other (Please specify)
Vacation
If paid vacation time is to be taken at the conclusion of the family leave or leave without pay, please specify:
Paid vacation dates from to (inclusive)
YYYY-MM-DD YYYY-MM-DD
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