<p> Leave of Absence Request Form</p><p>(Non FMLA/CFRA Employer)</p><p>Employee Name Request Date Status (check one) □ Full-Time □ Part-Time Date of Hire Dept </p><p>Employee Statement (to be completed by the employee)</p><p>I, (name) , request a leave of absence to begin on (date) </p><p> and to end on (date) for the following reason (check which box applies): </p><p>□ Medical: Employee’s own serious health condition (other than pregnancy or a pregnancy-related condition) □ Pregnancy: Employee’s disability due to pregnancy or a pregnancy-related condition. □ Family: To care for my family member with a serious health condition: family member </p><p>□ Bonding: To care for my newborn child or placement of a child with me for adoption/foster care □ Active Duty/Service member leave □ Other (please explain) </p><p>Are you or will you be applying for any type of wage replacement benefits such as State Disability or Workers’ Compensation while on unpaid leave? ______yes ______no</p><p>* I have read the sections of my Company’s employee handbook pertaining to the leave I am requesting and will provide all documents necessary. </p><p>Employee Signature Date</p><p>* All medical and pregnancy leave requests require a statement from the treating health care provider within 15 business days of request verifying the dates of disability/serious health condition, showing initial date of disability/serious health condition and expected return date. Additional medical certification may be required.</p><p>Note: Employees may not be eligible to accrue vacation/PTO, sick leave or holiday benefits while on an unpaid leave of absence. The policy provisions stated in the employee handbook will apply.</p><p>Employer Response (to be completed by the Human Resources Representative)</p><p>You have requested the following leave of absence: □ Pregnancy □ Medical □ Family □ Personal □ Military □ Other </p><p>Approval Leave approved □ </p><p>©2010 Silvers HR, LLC Form #4701:Rev 1 9/30/10 Leave not approved □ You are not eligible for the leave requested because .</p><p>Human Resources Representative Date </p><p>©2010 Silvers HR, LLC Form #4701:Rev 1 9/30/10 </p>