Military Leave: Designation of Representative Form

Directions: Complete this form, sign, and click “Submit”. This form will auto-generate an email to

HR.LAM.Office@hennepin.us with a PDF attached. Click “Send” to complete submission process.

Employee name: Employee ID #:

Department: Personal phone:

Email address (non-work):

Designation of Representative

In the event I am called to active military duty, I designate the following individual as my representative

to be contacted by Hennepin County should any county benefit issues require attention or action.

Representative’s name:

Relationship:

Mailing address:

City: State: Zip code:

Phone number:

Email address:

Acknowledgement

I have read and understand the information on the Hennepin County Military Leave webpage. I also

understand that this form will remain on file in the Human Resources Department until I rescind or revise it.

Date: Employee signature:

Learn how to sign forms electronically, or print a hardcopy, sign, and scan this form.

Hennepin County

Human Resources | LAM OfficeHR.LAM.Office@hennepin.us612-348-4082 | hennepin.us/employees