Special Unpaid Leave
Application Form – HR 108 (o)
This form is to be used by employees to apply for Special Unpaid Leave. You must give a
minimum of four weeks notice to your employer before commencing leave. This form should only
be completed where the absence is for leave of 11 months or less.
Please complete in Block Capitals/Tick appropriate boxes.
Section 1. To be completed by the employee
Surname: First Name:
Grade: Personnel No:
Location: PPS NO:
I hereby notify my employer that I wish to apply for Special Unpaid Leave.
Number of days Special Unpaid 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.
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:
HR 1
08 (o)_V2 Apr 2010 Page 1 of 2 Revised 01/04/2010
If faxing the form please ensure that the Employee’s Name and Personnel Number are included on each page of the
Personnel No:
HR 108 (o)_V2 Apr 2010 Page 2 of 2 Revised 01/04/2010
Section 5. Payroll Section
Location Code
Checked in Payroll
Name (Print) Signature
Tel No. Date
Section 6. Circulation List
1 2
3 4
5 6
7 8
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