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Tuesday for a period of six weeks. Applications for patterned long service leave require this form to be submitted in conjunction with a listing of all the individual dates you wish to have leave. Medical certificate must be attached. PAYMENT OPTIONS If long service leave is granted I request to receive please mark with an x See reverse for details on options available Standard fortnightly payments OR Payment in advance Advanced payment split over two financial years EMPLOYEES WHOSE SERVICE INCLUDES PART-TIME SERVICE Payment Entitlements See reverse for details on options available Average Rate Full Time Rate Nominated Percentage of Full Time Rate I hereby authorise all salary adjustments that may result from this leave application. I understand also that I must obtain written approval before undertaking any employment whilst on this leave and that failure to do so may result in formal disciplinary action. Applicant s signature / Date SECTION 3 RECOMMENDATION - SUPERVISING OFFICER Please Print Signature Position SECTION 4 DELEGATE APPROVAL Subject to entitlement SECTION 5 OFFICE USE Entitlement available YES NO If No Applicant / Delegate notified on Entered by Initials Checked by Initials Please turn over for details VL158 continued NOTES FOR GUIDANCE IN USE OF THIS FORM This form is for use by all DECD employees applying for long service leave. It is the responsibility of applicants to know the details of their long service leave entitlements. Information on long service leave entitlements is available on the departmental web sites including the appropriate Acts and Commissioner s Determinations. Please return to Payroll Team 05 Shared Services SA Courier R11/15 or DX 703 GPO Box 11026 Adelaide 5001 Ph 08 8462 1305 Press 1 Fax 08 8124 9605 VL158 Updated 07/11 Payroll Group APPLICATION FOR LONG SERVICE LEAVE SECTION 1 EMPLOYEE DETAILS PERSON ID Family Name Given Location Number Classification Job Title e.g. SSO1 Phone Email Please attach address details for communications whilst on leave if different to current residential address records held by State Office SECTION 2 LEAVE DETAILS All Employees to Complete Period of Leave From Total calendar days Patterned Long Service Leave Inclusive To To comprise Days at full pay Is this application for Long Service Leave in lieu of Sick Leave Yes Attach a full list of the dates for patterned LSL Days at half pay and / or NOTE Not available at half pay. Medical certificate must be attached. PAYMENT OPTIONS If long service leave is granted I request to receive please mark with an x See reverse for details on options available Standard fortnightly payments OR Payment in advance Advanced payment split over two financial years EMPLOYEES WHOSE SERVICE INCLUDES PART-TIME SERVICE Payment Entitlements See reverse for details on options available Average Rate Full Time Rate Nominated Percentage of Full Time Rate I hereby authorise all salary adjustments that may result from this leave application. I understand also that I must obtain written approval before undertaking any employment whilst on this leave and that failure to do so may result in formal disciplinary action. Applicant s signature / Date SECTION 3 RECOMMENDATION - SUPERVISING OFFICER Please Print Signature Position SECTION 4 DELEGATE APPROVAL Subject to entitlement SECTION 5 OFFICE USE Entitlement available YES NO If No Applicant / Delegate notified on Entered by Initials Checked by Initials Please turn over for details VL158 continued NOTES FOR GUIDANCE IN USE OF THIS FORM This form is for use by all DECD employees applying for long service leave.