Transcription of Family and Medical Leave Act Application Form
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Family and Medical Leave Act Application Form
Business Service Center Last Revised: 04/01/2012 Creation Date: 04/01/2012 Family and Medical Leave Act Application form HR-BEN-028 Section 1 - Information and Instructions The purpose of this form is to request a Leave of absence under the Family and Medical Leave Act ( FMLA ). Please mail or fax a signed copy of the completed form to your Agency Human Resources Department or FMLA Coordinator 30 days prior to the st art of your Leave or as soon as possible.
BSC ID . Last : First Agency ID. M.I. Suffix . Agency/De pt (check one) BSC B&T CC HQ Police Department : SIR LIRR MNR MTA Bus NYCT Job Title
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