Maternity Leave/additional Maternity Leave Application Form - Hr 108 (I)
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4Maternity Leave/Additional Maternity Leave
Application Form – HR 108 (i)
This form is to be used by employees to apply for Maternity Leave or additional Maternity Leave. Please note: You are required to give a
minimum of four weeks notice to your employer before taking Maternity Leave. Dates of Maternity Leave should be 26 weeks. Start date of
Additional (unpaid) Maternity Leave must be the day after finish date of Maternity Leave. Any additional leave e.g. Bank Holidays and Annual
Leave should be taken after Additional (unpaid) Maternity Leave finishes.
Please complete in Block Capitals/Tick appropriate boxes
To be completed by Employee
Surname:
First Name:
Grade:
Personnel No:
Location:
PPS No.
Absence Type
Start Date
End Date
D
D
M
M
Y
Y
Y
Y
D
D
M
M
Y
Y
Y
Y
Maternity Leave
D
D
M
M
Y
Y
Y
Y
D
D
M
M
Y
Y
Y
Y
Additional Maternity Leave
For Duration of each leave type please read appropriate HSE policy
Additional Information
D
D
M
M
Y
Y
Y
Y
Expected Date of Delivery
Doctors Stamp
Doctor’s Name:
Doctor’s Signature:
Note: When applying for maternity leave, please ensure your GP completes the section above or attach certification from Dept of Social,
Community and Family affairs.
Social Welfare
For staff paying Class A PRSI contributions
Please ensure that you have made application to the Department of Social Protection for payment of the appropriate benefit (MB 10 Form for
Maternity Benefit)
I have enclosed certification to confirm the expected date of delivery
I confirm that I have read and understand the maternity leave policy and the explanatory notes included in Appendix 1
D
D
M
M
Y
Y
Y
Y
Signature:
Date:
Name:
Contact Tel No:
HR 108(i)V2
Page 1 of 4
Revised 26/08/2014
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