Orion ISO MN Paid Family Medical Leave

Orion ISO MN Paid Family Medical Leave
Fill out this form to notify your employer of your intent to apply for MN Paid Family Medical Leave with the State of Minnesota. To request your leave please visit https://mn.gov/deed/paidleave/employees/.
Select your role:*

Self (I am the Employee)Orion Associates - Internal Use Only
Date of Communication*

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Date
Communication Method*
Upload Written Communication

Cancelof
Employee Legal Name

Legal First NameLegal Last Name
Employee Email
example@example.com
Employee Phone Number*
Please enter a valid phone number.
Type of Leave
Select the type of leave requested*

Paid Family LeavePaid Medical LeavePaid Family Leave - IntermittentPaid Medical Leave - IntermittentOther
Anticipate Leave Start Date*

MonthDayYear
Date
Anticipate Leave End Date*

MonthDayYear
Date
Comments
Supporting documentation (if applicable)

Cancelof
Signatures

I understand and accept that my electronic signature will be as valid as a handwritten signature and considered original to the extent allowed by applicable law. Please see the Consumer Consent Disclosure at https://www.jotform.com/consumer-consent-disclosure/
Name of person filling out the form*

Legal First NameLegal Last Name
Email of person filling out the form*
example@example.com
Signature*

Clear
Date of Signature*

MonthDayYear
Date
Please verify that you are human*
Should be Empty:

Type of Leave