Employee Leave Selection

EMPLOYEE LEAVE SELECTION

Personal Information

Full Name:    Employee ID:

Position Information

Reporting Manager:    Hire Date:

Leave Request Details

Please indicate the type(s) of leave requested (check all that apply):

Vacation / Paid Time Off (PTO)

Paid Sick Leave

Family and Medical Leave (FMLA or equivalent)

Medical Leave (non-FMLA)

Parental Leave

Bereavement Leave

Jury Duty

Personal Leave (unpaid)

Military Leave

Other (specify):

Leave Dates and Schedule

Anticipated Start Date:    Anticipated End Date:

Is this request for intermittent or reduced schedule leave?    Yes    No

Paid Time and Benefits Election

I elect to use accrued paid leave during this absence as provided by company policy:

Use accrued vacation/PTO

Use accrued sick leave

If unpaid leave is requested, indicate whether continuation of benefits is desired (subject to plan rules):    Yes    No

Reason for Leave and Supporting Documentation

I will provide supporting documentation (e.g., medical certification, court summons, death certificate) as required:    Yes    No

Employment History

Provide two most recent prior employers (for identity and verification). Include company name, title, dates, responsibilities, and reason for leaving.

Education

References

Provide three professional references (name, phone, email, relationship).

Legal Disclosures and Acknowledgments

At-Will Employment: I understand that my employment with the company is at-will unless otherwise provided by a written agreement signed by an authorized company representative. Nothing in this leave request shall modify the at-will nature of employment.

Equal Opportunity: The company is an equal opportunity employer. Leave decisions are made without regard to race, color, religion, sex, national origin, age, disability, or other protected characteristics, in accordance with applicable law.

Authorization to Obtain and Release Medical Information: I authorize any treating healthcare provider to release to the company (or its designee) medical information necessary to determine my eligibility for leave, to administer my benefits, and to determine necessary accommodations or return-to-work requirements. I further authorize the company to request additional medical clarification or fitness-for-duty documentation as permitted by law.

Authorization to Contact Prior Employers and Conduct Background Checks: I authorize the company to contact previous employers and references for verification purposes and to conduct background or employment verification checks when relevant to benefit administration or leave eligibility determinations.

Applicant Certification

I certify that all information provided in this Employee Leave Selection form is true, complete, and accurate to the best of my knowledge. I understand that providing false or misleading information may result in denial of leave, disciplinary action, or other employment consequences. I acknowledge that approval of leave is subject to applicable law, company policy, and receipt of required documentation.

I understand that I may be required to cooperate with the company in providing documentation, participating in return-to-work evaluations, and communicating regarding my intent to return. I authorize the company to place a leave status on my personnel record and to take appropriate action consistent with policy and law.

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