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2. First Name*
3. Last Name*
5. Primary Phone Number*
6. Primary Email Address*
7. Department*
9. Application Status

   1. Initial Application
   2. Revised Application
10. Requested Start Date*
    Requested Start Date
11. Anticipated End Date*
    Anticipated End Date
13. An FMLA leave of absence is a leave without pay. Paid leave (using accrued Personal Time Off/PTO hours) shall be substituted for the unpaid leave in accordance with the Family Medical Leave Act policy.
14. More information on the FMLA
    Department of Labor/FMLA
16. Hours of Accrued PTO*
17. Date Begins*
    Date Begins
18. Date Ends*
    Date Ends
20. I understand that I am required to complete a FMLA Leave Certification of Health Care Provider form (found on the City's web site) and submit the form to Human Resources before my leave commences. I understand that if my leave is approved, my time away from work will be charged againas my 12-week leave maximum under FMLA. Upon approval of this requested leave, I am required to utilize all paid time off available to me prior to going into an unpaid leave status. In the event that I go into an unpaid status while on leave, I understand that I must contact the City Clerk/Payroll Administrator to make arrangements to pay my portion of health insurance premiums.
22. I understand that one of the below Certification of Health Care Provider documents must be returned to Human Resources within 15 days of my request. If I am not able to return the form within the allowed timeframe, I will contact Human Resources for assistance. If this information is not received in the required timeframe, I understand that my leave may be considered unauthorized.
24. Form to request FMLA due to an employee's serious health condition:
    Certification of Health Care Provider - Employee
26. Form to request FMLA due to a family member's serious health condition:
    Certification of Health Care Provider - Family Member
28. Signature/Print Full Name*
29. Date*
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35. 1. Receive an email copy of this form.
36. Email address

    This field is not part of the form submission.

37. Submit Submit and Print

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