Free Maternity Leave Application Form Template

Maternity Leave Application Form

Please complete this form to formally apply for maternity leave.

Employee Information

Name

    Employee ID

      Department

        Job Title

          Supervisor’s Name

            Phone Number

              Email

                Leave Details

                Expected Start Date of Leave

                  Expected End Date of Leave

                    Estimated Delivery Date

                      Type of Leave Requested

                        • Paid Maternity Leave

                        • Unpaid Maternity Leave

                        • Short-Term Disability Leave (if applicable)

                        Health and Wellness

                        Doctor’s Name

                          Doctor’s Contact Number

                            Clinic/Hospital Name

                              Additional Information

                              Are you planning to work remotely before your leave begins?

                              If yes, specify remote work dates (if applicable):

                                Will you need to adjust your working hours prior to your leave?

                                If yes, specify adjusted hours and effective dates:

                                Specify any additional details.

                                  Do you plan to take any additional leave (e.g., vacation) immediately before or after your maternity leave?

                                  If yes, specify type and dates of additional leave:

                                  Specify any additional details.

                                    Contact During Leave

                                    Preferred Contact Method During Leave

                                      • Email

                                      • Phone

                                      • Text

                                      Emergency Contact Name

                                        Relationship to Applicant

                                          Phone Number

                                            Email

                                              Return to Work

                                              Expected Date of Return

                                                Will you require any accommodations upon your return?

                                                If yes, specify accommodation needs (if applicable):

                                                  By signing below, you confirm that all information provided is accurate, and you understand the company’s maternity leave policy as outlined in the employee handbook.

                                                  Signature of Applicant

                                                  Name:

                                                  Date:

                                                  Supervisor’s Signature

                                                  Name:

                                                  Date:

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