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Personal Leave of Absence Request— Non Family Medical Leave Act (FMLA)

Employee Statement

Personal Leave may be granted for Associates (up to 30 days) who wish to request time off for personal/medical reasons and

who are not eligible for the Family Medical Leave act (FMLA). Please submit the completed Leave Request by scan/email to

or by fax to (888) 882-5016. You may also mail the documents to the Benefits Department, 5815

Gulf Freeway, Houston, Texas 77023. This form is due to the Leave of Absence Administrator immediately.

Part A — Employee Information (All Information is Required)

Employee Full Name____________________________________ Alternate Contact Name:_______________________________

Street Address:___________________________________________ City & State:__________________________________

Zip Code ___________ Phone Number:_______________________ Alternate Contact Phone Number:_________________

Email (Personal):_____________________________________________ Preferred Method of Contact: _____Phone _____Email

Part B — Supervisor Information

DM/Supervisor’s Name (Required): ____________________________________Phone Number (Required):__________________

Date you notified your DM/Supervisor of your leave (Required):_______________

Part D — Paid Time Off (PTO) If Applicable (All Information is Required)

For Leave of Absences beginning 11/1/15 or later, Mattress Firm no longer requires Associates to use available PTO, while on

leave. You can choose to use all available PTO for the applicable days off, or use none.

Do you want the Leave Administrator to payout unused PTO through your unpaid Leave of Absence, or until PTO is exhausted,

whichever occurs first?:

______ Yes (available PTO will be applied)

______ No (No PTO will be applied)

**Note** Please do not request PTO through your DM/Supervisor. This must be applied by the Leave Administrator, to ensure you are paid

correctly.

Part D — Leave Information (All Information is Required)

Beginning Date of Leave: ____________________

Expected Return Date: ____________________

Reason for Leave:

____ Self (Medical)

____ Care of Spouse

____ Care of Child

____ Care of Parent

____ Birth of Child

____ Work Related (Worker’s Comp)

____ Other (Must Explain Below)

Detailed Reason for Leave:____________________________________________________________________________________

__________________________________________________________________________________________________________

Employee Signature: ___________________________________________________Date: ______________

DM/Supervisor Signature:___________________________________________________Date: ______________

Revised 10/15

Personal Leave Request Form

Mfrm Personal Leave Of Absence Request - Non Family Medical Leave Act (Fmla) Employee Statement