Application for Leave Form
Employee Name
*
Please Select
Arzen Magbag
Cherie Ryan
Chelsey Drumm
Eunice Gonzales
Beth Perry
Hollie Kent
Imogen Lyne
Lisa Macleod
Nicki Samson
Nikki Vanderwerf
Phil Bayne
Shane Wight
Email
*
Leave Type
*
Please Select
Sick/Carer's Leave
Annual Leave
Leave Without Pay
Time in Lieu
Unknown
If sick leave greater than one day, a medical certificate must be provided.
First Day of Leave
*
/
Day
/
Month
Year
Date
Last Day of Leave
*
/
Day
/
Month
Year
Date
Total Number of Working Days Off
*
Please write number of days (do not include public holidays)
Total Number of Hours Off
*
Please hours required for leave eg. 7.6 for one day (do not include public holidays)
Comments (if any)
Upload Medical Certificate Here (if required)
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Medical Cert / Permissions
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of
Print Name to Sign
*
Date
/
Day
/
Month
Year
Date
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