Leave Request Form (LRF)

I request a leave for the period and reason indicated:

Check the appropriate leave type which you want to apply. The signatures from the applying employee and supervisor are required for all cases. Valid for only one (1) type of leave per request. 

Employee acknowledges receipt of the below listed documents.

Employee must complete and return item 1 (If applicable)

1. Certification of Health Care Provider (Only for Medical leave: Applicable for C&D under FMLA)

2. Acknowledgement of Company Policy &Employee Obligations (Shown below, See attached)

I understand this leave is subject to the following terms & conditions: (Company Policy & Employee Obligations)

(1) I accept other employment during the period of this leave; my rights to certain compensation/benefits may be reduced or eliminated.

(2) I will return to work on the first day after this leave period expires, unless I have made other arrangements with the employer and have provided medical certification of my inability to return to work two (2) weeks prior to return date.

(3) Coverage under the various group insurance policies will not be continued by the company. (Applicable for LOA)

(4) I will be reinstated in my former position, or a similar one, unless conditions have so changed that neither my former neither position nor a similar one can be offered to me without presenting an undue burden on my employer.

(5) I should report my or my family’s condition in every two (2) weeks to store manager or HR department. It is recommended to call in every 2nd and 4th week of Monday. If necessary, I agreed to submit supporting documents.

If you were been denied for FMLA Application, please review the following information and instructions. For us to determine

as FMLA, you must return the following information to us within 15 calendar days from whether your absence qualifies receipt of this notice (additional time may be required in some circumstances

If sufficient information is not provided in a timely manner, your leave may be denied. 1 Sufficient certification to support your request for FMLA leaves. A certification form that sets forth the information necessary to support your request is enclosed. 2 Sufficient documentation to establish the required relationship between you and your family member. 3 Other information may need to re-process your request. HR department may send you separate notice.

If your leave does qualify as FMLA or LOA, you will have the following responsibilities while on leave

1 If wage replac ement benefits (such as short-ter m disability or workers' co mpensation benefits) are avai lable to y ou, you will be permitted to decide whether to use any other available Paid Time Off, so called “PTO” (such as vacation, sick, personal PTO has to be applied before the start day of leave to supplement such benefits. If you decide to use any of the se paid ti me off benefits available to you, you must complete and return any paperwork required to request the use of such benefits. The use of any available paid leave benefits will be considered part of your protected leave and will be counted against your leave entitlement. 2 If you do not qualify for wage replacement benefits (such as short-term disability or workers' compensation benefits), while on leave you will be permitted, at your discretion, available Paid Time Off, so called “PTO” (such as vacation, Sick, personal PTO has to be applied before the start day of leave to supplement such benefits. Any use of such paid ti me off benefits requires y ou to complete and return any paperwork required to request the use of such benefits. The use of any available paid leave benefits will be considered part of your protected leave and will be counted against your leave entitlement. 3 If you are equivalent and (or) above the managerial position, you are considered a “key employee” as defined by FMLA. As a “key employee,” restoration to em ployment may be denied following FMLA leave on the gro unds that such restoration will cause substantial and grievous economic injury to the Company. 4 While on leave you will be required to furnish us with periodic reports of your status and intent to return to work every two (2) weeks (Indicate interval of periodic reports, as appropriate for the particular leave situation

If the circumstances of your leave change, and you are planning to return to work earlier or later than the date originally indicated, you will be required to notify HR at least two (2) weeks prior to the date you intend to report for work.

If your leave does qualify as FMLA or LOA, you will have the following rights while on leave:

FMLA You have a right under the FMLA for up to 12 weeks of unpaid leave in a 12-month period calculated as a “rolling” 12-month period measured forward from the date each employee first uses any such leave. Successive 12-month periods commence on the date of the employee’s first use of any such leave after the preceding 12-month period has ended. You have a right under the FMLA for up to 26 weeks of unpaid leave in a single 12-month period to care for a covered service member with a serious injury or illness. Your health benefits must be maintained during any period of protected leave under the same conditions as if you continued to work. You must be reinstated to the same or an equivalent job with the same pay, benefits, and terms and conditions of employment on your return from FMLA-protected leave. (If your leave extends beyond the end of your FMLA-protected leave entitlement, you do not have return rights under FMLA If you do not return to work following FMLA leave for a reason other than: (1) the continuation, recurrence or onset of a serious health condition which would entitle you to leave; (2) the continuation, recurrence or onset of a covered service member’s serious injury or illness which would entitle you to FMLA leave; or (3) other circumstances beyond your control, you may be required to reimburse the Company for its share of health insurance premiums paid on your behalf during your FMLA leave. LOA You have a right under the LOA for up to certain months of unpaid leave based on seniority year.* For the permitted period, it differs by jurisdiction of Unions and given reason for taking the leave. For details, please contact the Human Resources Department for detail. While under LOA, coverage with the various group insurance policies will not be continued by the company.

FMLA If you are taking other employment during the period of this leave, your rights to certain compensation/benefits may be reduced or eliminated. You will return to work on the first day after this leave period expires, unless other arrangements with the employer and LOA have provided medical certification of your inability to return to work two (2) weeks prior to return date

Once we obtain the information from you as specified above, we will inform you, within 5 business days absent extenuating circumstances, whether your leave will be designated as FMLA leave and count towards your FMLA leave entitlement. If you have any questions, please do not hesitate to contact Human Resources Department.