Department of Labor Authorization Request Form
Submit your authorization request to the Department of Labor. All fields are required for processing.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Department
*
Please Select
Human Resources
Payroll
Compliance
Occupational Safety
Other
Type of Authorization Requested
*
Please Select
Access to Records
Leave Approval
Policy Exception
Other
Reason for Authorization Request
*
Supporting Documents (optional)
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Requested Effective Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Additional Comments (optional)
Signature
*
Submit Request
Submit Request
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