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Family and Medical Leave Act Application Form HR-BEN-028 Information and Instructions If you wish to request a leave of absence under the Family and Medical Leave Act (FMLA), please complete this

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1. Begin by carefully reading the instructions provided on the form or document that needs to be filled out. This will ensure that you understand the requirements and provide accurate information.
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1. Individuals who are required to submit forms or documents to a particular organization or institution, as specified in the instructions provided.
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The purpose of please mail or fax is to submit important information or documents to the recipient in a secure and timely manner.

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