Request for Maternity or Paternity Leave
Please do not use this form for FMLA. Please contact HR directly for that.
Employee Name
*
First Name
Last Name
Employee Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Hire Date
*
-
Month
-
Day
Year
Date
Location
*
Please Select
Boulder Creek Dining Company
The Bemberg
Bru Indianapolis
Bru Evansville
Bru Montgomery
Bru Noblesville
Bru Plainfield
Bru Westerville
Bru Keystone
Bru Brownsburg
Bru Bloomington
Bru Carmel
Bru Cincinnati
Bru Fort Mitchell
Bru Lexington
Bru Lafayette
Bru South Bend
Bru Ft Wayne
Bru Greenwood
Charbonos
Commission Row
CRG Delivery Kitchen
Test Kitchen
Elevance
CRG Event Center
CRG Grow
Cafe 251
Livery Indianapolis
Livery Montgomery
Livery Noblesville
Marquee
Mesh Indianapolis
Mesh Louisville
Modita
Nesso
Home Office
Provision
Rize IronWorks
Rize Fishers
Rize Carmel
Stone Creek Greenwood
Stone Creek Montgomery
Stone Creek Noblesville
Stone Creek Plainfield
Stone Creek West Chester
Stone Creek Zionsville
Shin Dig
Tavern at the Point
Theo's Italian
Union 50
Vida
Position Title
*
Manager's Name
*
Manager Email
*
example@example.com
Acknowledgement Section
Please acknowledge the following:
Please acknowledge ALL of the following requirements:
*
I have worked at CRG for at least 2 Continuous Years
I have worked at least 2500 hours in the 2 Years
I understand that the leave must be taken consecutively.
I understand that I will receive 60% of my regular pay during the approved leave period.
I understand that the paid leave maximum benefit is six business weeks or 30 paid days.
I understand that the leave must be applied for, approved, and taken within 90 days of the eligibility event (Ie. Birth/Adoption of child).
I understand that this is not a federally protected FML. In order to be approved for FMLA, I need to contact HR and request FMLA paperwork.
I understand that I muse use all PTO before this leave begins to pay and that the total leave between PTO and Paternity/Maternity is 6 weeks.
Details of Leave
Leave Request For
*
Days
Hours
Leave Start
*
-
Month
-
Day
Year
Date Picker Icon
Leave End
*
-
Month
-
Day
Year
Date Picker Icon
Leave Date
-
Month
-
Day
Year
Date
Time
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
Leave Type
*
Maternity
Paternity
Other
Leave Reason
*
Bonding With Newborn
Adoption
Foster Care Placement
Other
Please share any specific details that you would like for CRG to know.
Please upload any supporting documentation.
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