PART C:
If leave is requested to meet with a third party (such as to arrange fo
r childcare, to attend counseling, to attend
meetings with school or childcare providers, to make financial or legal arrangements, to act as the covered military
member’s representative before a federal, state, or local agency for purposes of obtaining, arranging or appealing
military service benefits, or to attend any event sponsored by the military or military service organizations), a
complete and sufficient certification includes the name, address, and appropriate contact information of the
individual or entity with whom you are meeting (
i.e.
, either the telephone or fax number or email address of the
individual or entity). This information may be used by your employer to verify that the information contained on
this form is accurate.
Name of Individual: ___________________________ Title: ___________________________________________
Organization: _________________________________________________________________________________
Address: ___________________________________________________________________
__________________
Telephone: (
________)_________________________ Fax: (_______)____________________________________
Email: ______________________________________
_________________________________________________
Describe nature of meeting: _________________
_____________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
PART D:
I certify that the information I provided above is true and correct.
___________________________________________ ________________________________________
Signature of Employee
Date
PAPERWORK REDUCTION ACT NOTICE AND PUBLIC BURDEN STATEMENT
If submitted, it is mandatory for employers to retain a copy of this discl
osure in their records for three years. 29 U.S.C. § 2616; 29
C.F.R. § 825.500. Persons are not required to respond to this collection of information unless it displays a currently valid OMB
control number. The Department of Labor estimates that it will take an average of 20 minutes for respondents to complete this
collection of information, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the
data needed, and completing and reviewing the collection of information. If you have any comments regarding this burden estimate
or any other aspect of this collection information, including suggestions for reducing this burden, send them to the Administrator,
Wage and Hour Division, U.S. Department of Labor, Room S-3502, 200 Constitution AV, NW, Washington, DC 20210. DO NOT
SEND THE COMPLETED FORM TO THE WAGE AND HOUR DIVISION; RETURN IT TO THE EMPLOYER.
Page 3 Form
WH-384 January 2009