Use your associate number or employee number to access your the Family Medical Leave Act form.
Associate Information:
Associate Number:
Associate First Name:
Associate Last Name:
Your request is for:
Choose one:
Birth, adoption or foster-placement of a child:
Care of spouse:
Care of child (must be under 18 years of age):
Care of parent:
Military Leave:
Care of military family member:
Your own serious health condition:
Important Message:
You will have to provide Human Resources with a completed
Certification of Physician or Practitioner Form
within 15 days of today's date (Return by date is March 25, 2010). If you fail to provide this form, your rights or benefits under this policy can be denied or delayed.