Maternity Leave/additional Maternity Leave Application Form

Maternity Leave/additional Maternity Leave Application Form - Hr 108 (I) Page 2

If Faxing please ensure Employee’s Name and Personnel Number are included for each page of form

Name:________________________ Personnel No:__________________________

To Be Completed By Line Manager

Checklist

All PRSI Class A Employees

EDD/Placement Cert received

MB10/AB1 to Dept S.W.

Class D Officers

EDD/Placement Cert received

Average Hours worked per week

(Hours to be paid on Maternity Leave)

If this employee on a fixed term or specified purpose contract please indicate if the

Yes

period of leave applied for is covered by the tenure of their contract

If No please provide expiry date of contract

I have checked the relevant supporting documentation requires for the leave requested and confirm that this application complies with the terms

outlined in the relevant HR policy

Signature

Name (Capitals)

Grade

Contact Phone No

Mobile No

e-mail address

Local Payroll

Location Code

Name:

Signature:

Tel No

Date

To Be Completed by Human Resources

System updated by:

Name:

Tel No:

Date

Comments:

Circulation List

HR 108(i)_V2 Apr 2013

Page 2 of 4

Revised 26/08/2014

Maternity Leave/additional Maternity Leave Application Form - Hr 108 (I) Page 2