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


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
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


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