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Maternity Leave Request - Template, Sample Form

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Re: Maternity leave application;


Dear Sir or Madam,

I am writing to formally apply for maternity leave due to my pregnancy, and I intend for my leave application to start on ________. Attached herewith is a medical certificate issued by my physician showing the details of my pregnancy which states that the estimated date of my delivery is ________.

Pursuant to R.A. 11210 or the Expanded Maternity Leave, I am entitled to claim a maternity leave for a period of one hundred and five (105) days.

You may contact me at ________, and if I may be unreachable using my contact details during my leave, I will be happy to discuss matters that require my attention upon my return.

Thank you.


Sincerely,



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Fields you complete are inserted into the document live. This template is general guidance only - not legal advice.