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EMPLOYEE NAME Please print Last LAST 4 DIGITS OF SOCIAL SECURITY First Middle REGION / BRANCH / DIVISION FROM Beginning Date PERIOD POSITION NUMBER CLASSIFICATION WORK PHONE NUMBER To Ending Date I WILL RETURN TO PAY STATUS ON Date REASON FOR LEAVE OF ABSENCE CHECK APPROPRIATE BOX ES INITIAL REQUEST EXTENSION EDUCATION May affect medical benefits FMLA/CFRA Must meet other eligibility requirements Note See your supervisor for eligibility requirements ILLNESS SDI-STATE DISABILITY INSURANCE...

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