Application Form – HR 108 (j)
This form is to be used by employee
s to apply for Parental Leave
Please complete in Block Capitals/Tick appropriate boxes
Information will be input on the HR/Payroll System for the purposes of Personnel and Payroll Administration.
Date field format DDMMYY
HR 108 (j)_V2 Apr 2010 Page 1 of 3 Revised 01/04/2010
Section1. To be completed by the employee
Surname: First Name:
Grade: Personnel No:
Location: PPS No:
Name of child:
Date of birth of child:
Date of adoption order (if applicable)
Please note that this notification should be accompanied by the birth certificate or adoption order of the child.
Section 2. Please provide details of the manner in which you propose to take
Section 3. Please Give Details of the Duration of the proposed Parental Leave
Section 4. Date on which you propose to commence Parental Leave
Proposed commencement date
Section 5. Confirmation
I declare the information given above is true and correct. I also declare that I have read and understand all
the terms and conditions of the Parental Leave Scheme. I understand that the leave must be used for the
purpose for which it is being sought.