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<br /> <br /> Form FMLA-1 <br /> <br />CITY OF PARIS <br /> <br />FAMILY AND MEDICAL LEAVE FORM <br />REQUEST FORM <br /> <br /> TO BE COMPLETED BY THE EMPLOYEE <br />Employee Name________________________________________________________________ <br /> <br />Department/Division_____________________________________________________________ <br /> <br /> <br /> <br />Reason for request: <br /> Personal Illness <br />? <br /> Family Illness <br />? <br /> Birth or adoption of a child <br />? <br /> <br />If leave is for a family illness, name and relationship of family member: <br />______________________________________________________________________________ <br /> <br />Duration of leave _______________________________________________________________ <br /> <br /> <br /> <br />I hereby authorize the attending physician to release information required on this leave request. <br /> <br />_______________________________________ _________________ <br />Signature of employee Date <br />_______________________________________ _________________ <br />Signature of Family Member (if applicable) Date <br /> 66 <br />Revised: 3/1/2006 <br />