Sample Form Cuti

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PT. ..........

Form leave - 01 / Revisi 2011

LEAVE APPLICATION
Name Dept. Position Entry Date
: : : :

Address
(at which you can be reached during leave)

Phone No.

I. Type of leave requested


Annual leave Marriage Leave Maternal Leave (please attach the certificate from physycian or hospital ) Others

II. The Purpose of Leave

III. During leave, daily duties to be performed by :


Name Position : :

IV. Period Of Leave Request


Starting from (date) Until (date) Number of leave day (s) Note : : : :

Remaining Leave Entitlement (to be filled in by HR Dept)


Remaining leave entitlement for past period Leave entitlement for current period TOTAL : : : day(s) day(s) day(s) day(s)

Approved Leave
Remaining Leave entitlement per 2012 :

Requesting Employee,

HR Dept.

name & date

name & date

V. Leave Approval Reason

Approved

Refused

Adjourned

Approved by,

Acknowledge by,

Verified by,

manager

VP/Director

HR Dept.

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