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1. What is your name?
2. What is your job title?
3. What is your health issue to request work from home?
4. What is the period of time you want to request? (XX to XX)
5. If you have a copy of the doctor's medical report, mention it here. (Or you can leave it blank)
6. Who are you writing this request for?
7. What is the employer's job title?
8. What is your company name?
9. What is your company address?
10. What is your contact email and phone no.?
11. What's today's date?