Orion ISO FS MN Paid Family Medical Leave

Orion ISO FS 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 apply for a leave of absence, please visit https://mn.gov/deed/paidleave/employees/.
Select your role*

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

MonthDayYear
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.
Please indicate the Participant that you work with and intend to take leave from and submit one form for each Participant.
Participant First Name*

First NameLast Name
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
Describe the family member or service member's relationship to the employee*
Mother, father, sister, etc.
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:

Orion ISO FS MN Paid Family Medical Leave

Type of Leave

Signatures