Maternity Leave Application Form printable pdf download

Maternity Leave Application Form

To access maternity leave and pay, you must notify the Lead Employer Trust (LET) at least 15 weeks before the expected

week of childbirth (EWC). All boxes marked with an asterix (*) are mandatory.

PART 1: Employee Details

Surname: *

Forename: *

Email address: *

Address: *

Tel. number: *

GMC number: *

Programme: *

Grade (e.g. ST3): *

☐

Are you a Tier 2 visa holder? *

Yes

PART 2: Maternity Leave Details

Expected date of childbirth: *

☐

MAT B1 provided: *

Enclosed

To Follow

First date of maternity leave: *

Do you wish to have your Occupational Maternity Pay (i.e. 8 weeks at full pay and

☐

Yes

18 weeks at half pay), if eligible, spread equally over the leave period? *

PART 3: Return to Work Details

☐

I intend to return to work after maternity leave: *

Yes

Expected end date for maternity leave: *

PART 4: Accrued Annual Leave and Bank Holidays

I intend to take all annual leave I accrue during my

☐

Yes

Not decided

maternity leave prior to returning to work:*

Please confirm dates of any agreed annual leave:

PART 5: Declaration

I wish to apply for maternity leave with pay as appropriate in accordance with the LET’s Parental Leave Policy and the NHS

Terms and Conditions of Service Handbook.

I declare that it is my intention to continue in the service of the LET or another NHS employing authority for at least three

months after my return to duty.

If my fixed term contract ends after the 11th week before the EWC and before 6 weeks after the EWC, I agree that my

contract may be extended to receive 39 weeks paid leave (please note weeks 27-39 will be at SMP only).

If I fail to return to work I agree to refund the whole of the maternity pay I will have received (apart from that to which I am

entitled under the Social Security Act 1986).

I agree to take at least two weeks compulsory maternity leave.

I agree to notify the LET of any requested changes to my pay arrangements no later than 28 days before maternity pay

commences.

If I wish to change my return to work date, I agree to give at least 28 days’ notice of the change.

PART 6: Employee Declaration

Name: *

Signature: *

Date: *

PART 7: Manager Authorisation (Host training organisation at the time maternity leave will commence)

Name: *

Signature: *

Date: *

Please send the completed form and your MAT B1 form to your HR Officer at the Lead Employer Trust.

Maternity Leave Application Form

Related Articles

Related forms

Related Categories