This form should be completed if :
Leave is for five (5) working days and should be taken after Indiviudal spouse/common law partner has undergone C-section surgery. All male applicants should be working for at least twelve months continuously.
Employee
*
First Name
Last Name
ID#
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Medical Benefit #
Social Security #
Department or Location
*
Name of spouse
First Name
Last Name
Date of birth /expected date of birth
-
Month
-
Day
Year
Date
Number of days applying for
Traveling overseas
Yes
No
Is yes, intended address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date requested from
*
-
Day
-
Month
Year
Date
Date requested to
*
-
Day
-
Month
Year
Date
Resume work on
-
Day
-
Month
Year
Date
Employee’s Signature
Date
-
Month
-
Day
Year
Date
Relieving officer(s):
Date
-
Month
-
Day
Year
Date
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Scheduling agent remarks
Date
-
Month
-
Day
Year
Date
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Ops manager remarks
ops manager signature.
Date received
-
Month
-
Day
Year
Date
Approved by Human Resource manager
Yes
No
HR manager remarks
HRM Signature
Date
-
Month
-
Day
Year
Date
Reviewed by
Office manager
General manager
Managing director
Remarks
Signature
Submit
Should be Empty: