Pregnancy Disability Leave Request Form Page 2

Pregnancy Disability Leave Request Form 09/09/15

EMPLOYEE STATEMENT

I certify that I have read and understand the pregnancy disability leave of absence policy. I understand the

instructions on this form and will comply with the leave of absence policy.

Employee Signature: ________________________________________

Date: _____________________

Print Name: _______________________________________________

OFFICE MANAGER

Manager Signature: _________________________________________

Date: ________________________

Print Name: _______________________________________________

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