Application Form For Maternity Leave Entitlements


Circular 0009/2013 Appendix A
Application Form for Maternity Leave Entitlements
This application must be fully completed and retained in the school for record and audit purposes.
It can be used to apply for maternity and/or statutory and/or non statutory unpaid maternity leave.
It should be completed and submitted at least 6 weeks before the leave is due to commence.
This application is NOT to be submitted to the Department of Education and Skills.
If the applicant pays Class A PRSI contributions a completed MB10 Form should be submitted to
the DSP. This Form is available from the DSP or online at:
Maternity Leave
Statutory Unpaid Maternity Leave
Non-Statutory Unpaid Maternity Leave
lease tick as appropriate
Roll No.
Contact No: _
__ PPSN:
Expected date of birth (EDB)
(Medical certificate must be enclosed confirming expected date of birth)
I wish to commence my maternity leave on
State the number of days statutory additional unpaid maternity leave that are to be taken (if any):
(Consecutive days and to include weekends)
Statutory Additional Unpaid Maternity Leave from
inclusive dates)
A teacher on completion of maternity leave and statutory additional unpaid maternity leave may
apply for ‘non-statutory additional unpaid maternity leave to the end of the school year’.
Non-Statutory Additional Unpaid Maternity leave to the end of the school year from
to 31
I wish to apply for the above leave in accordance with the terms of
Circular 0009/2013
Signature of teacher:
Date: _


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