Leave Application Form

Employee Details
Position Title
Employee Number



Type Of Leave

Personal Leave

Medical Certificate

Annual Leave

Annual Leave Amendment / Cancellation

Long Service Leave

Leave Without Pay

Parental Leave

Attach Relevant Documentation

Bereavement Leave

Attach Relevant Documentation

Other Leave

Attach Relevant Documentation


Period of Leave
First Working Day of Leave
Last Working Day of Leave
Date of Return to Work
Number of Working Days
Number of RDO's
Number of Public Holidays
Total Leave Days


Employee Approval
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.