PT.

BSR INDONESIA
LEAVE REQUESITION FORM
I. Employee Detail

Name :
NIP :
Job Tittle :
Dept/Div :
Unit :
II. Type Of Leave

Annual
Years :
Without Pay
Others

(thick & specify) :

Period : from ____________________________________to______________________________

Previous Balance : ___________________________ days

To be taken : ___________________________ days
Last Balance : ___________________________ days

III. Contact Address

Address : _____________________________________________________________________________
Email : _____________________________________________________________________________
Phone No : _____________________________________________________________________________
Mobile Phone : _____________________________________________________________________________

IV. Caretakers
While I am away,my job will be handle by:
Alternate 1 Alternate 2
Nama : ___________________________ Nama : ___________________________
Phone/Ext : ___________________________ Phone/Ext : ___________________________
Incharge for : ___________________________ Incharge for : ___________________________
Authority Level : ___________________________ Authority Level : ___________________________
Dates Eff Incharge : __________to_______________ Dates Eff Incharge : __________to_______________
Signature : ___________________________ Signature : ___________________________

V. Authorization

Request by, Approved by,

Name : _________________________ Name : ______________________ Name : ___________________________

Date : _________________________ Date : ______________________ Date : ___________________________

HR for File
Received by, Remarks:

Name : __________________________ _________________________________________________________

Date : __________________________ _________________________________________________________