Application Form For Maternity Leave Entitlements printable pdf download

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:

APPLICATION IN RESPECT OF:

□

Maternity Leave

Statutory Unpaid Maternity Leave

Non-Statutory Unpaid Maternity Leave

lease tick as appropriate

Name:

School:

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

(enter

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

August

I wish to apply for the above leave in accordance with the terms of

Circular 0009/2013

Signature of teacher:

___

Date: _

Application Form For Maternity Leave Entitlements