Title Page
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Document No.
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Who do you work for
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Chose your name
- Alwyn
- Barry
- Caley
- Carl
- Chris
- Colin
- Colton
- Dave
- Fiona
- Frodo
- George
- Glenys
- Tracy
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Choose your name
- Dave B
- Shane
- Sele
- Hayden Wal
- Hayden Wib
- Ofisa
- Tasi
- Glen
- Corey
- Fuifui
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Date the form was filled out:
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I wish to apply for the following leave:
- Annual Leave
- Unpaid Annual Leave (no leave owing or accrued)
- Sick Leave
- Unpaid Sick Leave
- Bereavement Leave (immediate)
- Bereavement Leave (close association
- Jury Service
- Study Leave
- Leave of absence (unpaid)
- ACC (work related)
- ACC (non work related)
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Total Days
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First Date of Leave:
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Date Due Back
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Reason for absence
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Employee's Signature
