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Z1 a APPLICATION FOR LEAVE OF ABSENCE Initials Surname PERSAL Number Shift Worker Address During The Leave Period Yes Casual Employee No Department Component Tel. No. Type Of Leave Taken As Working Days Annual Leave Normal Sick Leave1 Temporary Incapacity Leave Start Date End Date Number Of Working Days This application form must not be used to apply for temporary incapacity leave. Temporary incapacity Leave must be applied for on the application form prescribed in terms of the Management Policy and Procedure on Incapacity Leave and Ill-health Retirement for Public Service Employees. Please contact your Personnel Office for further information* Leave for Occupational Injuries and Diseases Specify Type of Illness Adoption Leave2 Family Responsibility Leave Provide Evidence Special Leave Leave For Union Office Bearers Provide Evidence Unpaid Leave Provide motivation Maternity Leave Attach medical certificate Number Of Calendar Days No* of Calendar Months I hereby certify that the information provided is correct. Any falsification of information in this regard may form ground for disciplinary action* Furthermore I full understand that if I do not have sufficient leave credits from my previous or current leave cycle to cover for my application my capped leave as at 30 June 2000 will be automatically utilised*. EMPLOYEE SIGNATURE DATE Recommendation By Supervisor/Manager Mark with X Recommended Rescheduled REMARKS If not recommended please state the reasons the dates in the case of rescheduling MANAGER S/SUPERVISOR S SIGNATURE. Approval By Head of Department Mark With X Approved With Full Pay Not Approved REMARKS If approved with a change in condition of payment or not approved please provide motivation SIGNATURE OF HOD OR DESIGNEE DATA CAPTURING CAPTURED BY CAPTURED ON CHECKED BY. CHECKED ON. Applications in respect of sick leave of three or more days must be accompanied by a medical certificate issued by a registered medical practitioner. Temporary incapacity Leave must be applied for on the application form prescribed in terms of the Management Policy and Procedure on Incapacity Leave and Ill-health Retirement for Public Service Employees. Please contact your Personnel Office for further information* Leave for Occupational Injuries and Diseases Specify Type of Illness Adoption Leave2 Family Responsibility Leave Provide Evidence Special Leave Leave For Union Office Bearers Provide Evidence Unpaid Leave Provide motivation Maternity Leave Attach medical certificate Number Of Calendar Days No* of Calendar Months I hereby certify that the information provided is correct. Please contact your Personnel Office for further information* Leave for Occupational Injuries and Diseases Specify Type of Illness Adoption Leave2 Family Responsibility Leave Provide Evidence Special Leave Leave For Union Office Bearers Provide Evidence Unpaid Leave Provide motivation Maternity Leave Attach medical certificate Number Of Calendar Days No* of Calendar Months I hereby certify that the information provided is correct. Any falsification of information in this regard may form ground for disciplinary action* Furthermore I full understand that if I do not have sufficient leave credits from my previous or current leave cycle to cover for my application my capped leave as at 30 June 2000 will be automatically utilised*. .

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