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
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
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:
Application Form Templates @ Template.net