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<br />Attachment 2 <br /> <br />Form FMLA-l <br /> <br />CITY OF PARIS <br />F AMIL Y AND MEDICAL LEAVE FORM <br />REQUEST FORM <br /> <br />TO BE COMPLETED BY THE EMPLOYEE <br />Employee Name <br /> <br />Department/Division <br /> <br />Reason for request: <br />o Personal Illness <br />o Family Illness <br />o Birth or adoption of a child <br /> <br />If leave is for a family illness, name and relationship of family member: <br /> <br />Duration of leave <br /> <br />I hereby authorize the attending physician to release information required on this leave request. <br /> <br />Signature of employee <br /> <br />Date <br /> <br />Signature of Family Member (if applicable) <br /> <br />Date <br /> <br />68 <br /> <br />Revised 01-25-05 <br />