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Nce Request Form PLEASE PRINT Employee Name: SSN: Home Address: City, State, Zip: Job Title: Dept. Name: REASON FOR LEAVE REQUEST Domestic or sexual violence of employee Domestic or sexual violence of family or household member Name of individual: Relationship: EXPECTED DURATION OF THE REQUESTED LEAVE BLOCK OF TIME from to (month/day/year) (month/day/year) INTERMITTENT LEAVE*: Describe anticipated frequency and duration.

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