First Name

Last Name

Email Address

Position

Leave Type

Please tick the appropriate boxes. If you are applying for more than one type of leave, please specify the details in the comments section provided.

• Annual Leave
• Sick leave

Note: Upon termination of employment, leave taken that has not been accrued can be withheld from wages.

• Leave without pay
• Other

Comments

Last day of work:

Return to work:

Number of days:

Note: Do not include any public holiday or substitued days in the total.