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465 <br />Attachment 2 <br />Form FMLA -1 <br />CITY OF PARIS. <br />FAMILY AND MEDICAL LEAVE FORM <br />REQUEST FORM <br />TO BE COMPLETED BY THE EMPLOYE - - <br />Employee Name <br />Reason for request: <br />i <br />❑ Personal Illness <br />i <br />❑ Family Illness <br />❑ Birth or adoption of a child <br />If leave is for a family <br />llne <br />y ss, name and relationship of family member: <br />Duration of leave <br />I hereby authorize the attending physician to release information required on this leave request. <br />Signature of employee <br />Date <br />Signature of Family Member (if applicable) <br />Date <br />68 <br />Revised 01 -25 -05 <br />