4430.01 f4/page 1 of 1 fitness-for-duty certification fmla leave (to be submitted prior to reinstatement) employee's name: position: building: employee's serious health condition which caused him/her to take fmla leave: date fmla leave commenced:...
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Republic of the philippines social security system medical certificate ( form mmd - 102) 1. employee s general data name (last, first, m.i.) age sex civil status occupation date examined/attended to from 2. brief clinical history and present...
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D myan ar m n artmen ep marine ad of m i stratio ni t government of the republic of the union of myanmar ministry of transport department of marine administration yangon, myanmar medical certificate for myanmar seafarer n e im c e p s issued under...
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Datedepartment of housing, buildings and constructiondivision of plumbing101 sea hero rd, suite 100frankfort, ky 406015412dear sir:i, (your name), licensed master (your license number), do hereby notify you that iwill no longer represent, (company...
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Student leave application form nb: if you have more than one placement, please complete a separate form for each appointment. full name employee number position title organisation unit details of leave full days full days part days part days leave...
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Cigna healthcare po box 183 chattanooga, tn 37422 date member name member address city, state zip if you need a certificate of credible coverage please contact cigna customer service at 1-800-cigna24 1-800-244-6224 re: certificate group health...
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Parochial church council of the ecclesiastical parish of st marys, charlton kings sickness selfcertification this form should be completed on your return to work following any period of sickness. if you are returning to work after a period of...
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Hr division sickness absence notification 03/09 this form should be completed when a member of staff returns to work after sick leave or, if still on sick leave, whenever a doctors certificate is supplied. staff can selfcertify absences of seven...
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Section 5 medical certificate padca form 2 to be completed by medical practitioner patients full name: age: 1. sex: weight: serious medical conditions (eg previous coronary or cva) 2. operations (eg hysterectomy, hip replacement, heart bypass) 3....
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Medical certificate requestaccording to colorado springs utilities rules and regulations, a customer may provide a signed medical certificateto postpone the discontinuance of utility service. a medical certificate is a document signed by a...
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Bravo personnel consultancy limited tel:2881 6923 fax: 2576 8026 email: resume bravopersonnel.com leave application form for temporary staff ( annual leave / sick leave with medical certificate / no pay leave ) name of staff : company : period :...
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Environmental health and housing mintlyn crematorium, lynn road, bawsey, king's lynn, norfolk pe32 1hb tel: (01553) 630533 fax: (01553) 630998 cremation 4 replacing form b medical certificate details of the deceased this form can only be completed...
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Faculty of education students leave application form fed/form/005 student name : major: dates of leave: student no.: contact no.: from / / to / / total no. of days: dd mm y dd reason for leave: (please the appropriate.) sick leave compassionate...
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