Work Flex Application

Name:  [text name="variable_1" default="      "]

ID Number: [text name="variable_2" default=" "]

Eiligibility for STD , FMLA, Cobra, LOA, etc: [checkbox name="variable_1" value="Yes | No "]

Name of company: [text name="variable_3" default=" "]

Contact information for company, HR, etc: [textarea name="variable_1" default="  "]

Authorized to work from home: [checkbox name="variable_2" value="Yes | no"]

Access to personal technology [checkbox name="variable_3" value="Yes | No "]

Ability to complete all tasks in allotted time period: [checkbox name="variable_4" value="Yes | No "] [textarea name="variable_15" default=" "]

FLOS: [checkbox name="variable_10" value="Yes| No"]

Full ROI for employer: [checkbox name="variable_20" value="Yes| No"]

Adherance and undersatnding of work flex expectations / Treatment Enhancement Agreement: [checkbox name="variable_33" value="Yes | No"]