Sample application for medical leave

Sample application for medical leave.


The Manager

Firm/Company Name


Dear Sir

I have been suffering from an acute attack of sciatica for the last five days. I have been advised complete rest for a period of 30 days by the doctor. I, therefore, request you to kindly grant me medical leave (half pay leave commuted into full pay leave) for 30 days with effect from …………… (date) to …………… (date).

I am enclosing a medical certificate from my doctor.

Thanking you.


Yours faithfully,

P.K. Gupta

The Family and Medical Leave Act: Your Questions Answered | Paychex

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