Leave Application Form
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1
2
3Author: Business Process Co-ordinator
Document ID: FM100021
Approved by: State Manager, RETS
Version: 3.2
Modified: 13 January 2017
Published: 2 November 2011
Leave Application Form
COMPLETE THIS FORM ONLINE, and then PRINT and SIGN.
To move between fields use the tab key, to select a checkbox use the spacebar on your keyboard.
Assignment
-
Number
Surname
Given Name (s)
Position Title
Location/Facility
Contact Phone
(Mandatory)
Number
New
Date of
New Application or Amended Application
Amended
Original
LEAVE
PAID MATERNITY/
TYPES
ANNUAL
SICK/CARERS
FACS
LWOP
LSL
L&D/CONFERENCE
ADOPTION/
PARENTAL
Insert into the first column, the leave type applicable from the list above. Multiple leave types should be entered in date order.
First Day Of
Last Day of
Type
Leave
Leave
First Day Of
Last Day of
Type
Leave
Leave
First Day Of
Last Day of
Type
Leave
Leave
First Day Of
Last Day of
Type
Leave
Leave
First Day Of
Last Day of
Type
Leave
Leave
Will any ADO’s be
Yes
No
Dates
(DD-MMM-YY)
taken during leave
Provide Dates
Reasons/Comments for Leave:
Date (DD-MMM-YY):
Return to work
Pay in advance is for Annual, Long Service and Maternity Leave only. Applications
Is pay required in
must be sent to the Pay Office 4 weeks prior to your leave commencing. A copy of
Yes
No
advance
your roster leading up to your leave (minimum of 2 weeks) must be supplied with
(Tick appropriate box)
this application to allow payment to occur prior to leave commencing.
Half pay Leave
Double Pay
Yes
Note: ½ pay options are only for Parental and
Yes
No
(
(Tick appropriate box)
Tick appropriate box)
No
LSL. Double pay option is only for LSL.
(Excluded Casuals)
(Excludes Casuals)
Are relevant
Medical certificate
Note: Documentation may be required for Sick Leave, Maternity, Adoption &
documents
Statutory Declaration
Parental Leave, FACS, and Carers Leave.
attached
Other
(Tick appropriate box)
Maternity / Adoption / Parental Leave ONLY
Note: A Medical Certificate from your treating Doctor or Registered Midwife
Expected date of
Date (DD-MMM-YY)
stating the expected date of confinement must be attached for Maternity or
confinement
Parental Leave.
Reduced Hours Per Week
Return to Substantive Date (if defined)
Returning to work
Yes
No
on Reduced Hours
Note: This form applies to Leave Applications only. When an employee is to Return to Work on Reduced Hours, a FM100011
Employment Details Change Form or Employment Details Change (Return to Work) eForm is to be completed.
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Parent category: Business