Special Leave on Marriage
Application Form – HR 108 (n)
This form is to be used by employees to apply for Special Leave on Marriage. You must give a
minimum of four weeks notice to your employer before commencing leave.
Please complete in Block Capitals/Tick appropriate boxes
All employees may be allowed up to a maximum of five days’ special leave with pay when they marry,
provided the amount of special leave granted for this purpose together with the annual leave allowance in
respect of the leave year in which the marriage takes place does not exceed a total of 24 days or hourly
equivalent, (or where appropriate a pro-rata entitlement) excluding any annual leave carried over from the
previous year.
c.f. Department of Health Circular No. S116/48
& Department of Health and Children Circular dated 11 July 1997
HR 1
08 (n)_V2 Apr 2010 Page 1 of 2 Revised 01/04/2010
Section 1. To be completed by the employee
Surname: First Name:
Grade: Personnel No:
Location: PPS No:
In accordance with the provisions of the HSE Terms and Conditions of Employment (Revised) 2009.I hereby notify
my employer that I intend to take Special Leave on Marriage.
Number of days leave applied for:
From date
To date
Signature Date
Section 2. To be Completed by the Line Manager
I have checked the relevant supporting documentation required for the leave requested and confirm that the leave
required complies with the terms outlined in the relavant HR policy
Application Approved Yes No If no, give reason:
Signature: Date:
Name: Grade:
Contact Phone No: Mobile No:
Email Address:
Section 3. Delegated Officer Approval
Name (Print) Signature
Tel No Date
Decision No
Section 4. To be completed by Human Resources Personnel Administration
System updated by: Name:
Contact Phone No: Date:
If faxing the form please ensure that the Employee’s Name and Personnel Number are included on each page of the
Name: Personnel Number:
HR 108 (n)_V2 Apr 2010 Page 2 of 2 Revised 01/04/2010
Section 5. Payroll Section
Location Code
Checked by Payroll
Name (Print) Signature
Tel No Date
Section 6. Circulation List
1 2
3 4
5 6
7 8
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