MEDICAL LEAVE APPLICATION

[Your Company Name]

Please fill all required spaces in this Medical Leave Application form:

Employee Information:

Employee Name:	[Employee Name]
Position:	[Position]
Department:	[Department]
Employee ID:	[Employee ID]
Contact No.:	[Contact Number]
Email Address:	[Email Address]

Leave Details:

Type of Leave:	Medical Leave
Start Date:	[Start Date]
End Date:	[End Date]
Total Days:	[Total Number of Days]
Reason for Leave:	[Reason for Medical Leave]

Medical Documentation

Attach medical certificates, doctor's notes, or any relevant documentation.

File Attached:

• Yes

• No

Supervisor Information

Supervisor Name:	[Supervisor Name]
Position:	[Position]
Contact No.:	[Contact Number]
Email Address:	[Email Address]

Employee Declaration

I, [Employee Name], hereby declare that the information provided above is accurate and true to the best of my knowledge. I understand that false information may lead to termination of employment or other disciplinary action.

Signature: [Signature]

Date: [Date]

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For HR Department Use Only

Application Status:	Approved Denied
Reviewed By:	[HR Representative Name]
Date Reviewed:	[Date Reviewed]
Comments:	[HR Comments]

Please submit this completed form along with any necessary medical documentation to the HR Department. For any questions or clarification, contact [HR Contact Details].

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This form is in accordance with company policy and adheres to state and federal laws regarding medical leave.

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