Name *

First Name

Last Name

Date Leaving Work *

MM

DD

YYYY

Date Returning to Work *

MM

DD

YYYY

Acknowledgement *

I am expected to provide documentation to the Company's HR manager, whenever possible, concerning the reasons for any absences from or tardiness to work, and I must also complete all company forms required due to missing work for personal or family medical or health issues, visits to a medical or dental facility or provider, funerals, jury duty, personal business, court appearances, or any other reasons. I further understand that this documentation must be provided no later the second business day following the date(s) I missed or was tardy.

Agree