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APPLICATION FOR LEAVE

Employee Name : ……………………..

Position / Employment Date : …………………….

Department / Employee No. : ……………………

Year of leave applied / expiry date : ………….. / ……………..


(Minimum service is at least after 12 consecutive months / Entitled leave will expire one year after employment
anniversary date)
Contact Address (Jakarta/Blora) :

Contact Address during vacation : ……………………………….

Reason of Leave : ………………………….

Annual Leave Period : From ……………….…….. to ………………….…..

Special Leave Period : From ……………….…….. to ………………….…..

Jakarta, …………….. 2017

Signature of Applicant
HR SECTION:
Accumulated annual leave entitlement : 12 (Twelve) days
Absent (Without Doctor’s letter / written :
justification)
Leave Balance Entitlement to this date :
Leave to be taken this period :
Advance Leave has been taken :
No. of leave day(s) to be carried over :

Remarks:

Verified by Personnel & Admin. Endorsed by Human Resources Approved by Department Manager
Supervisor Superintendent

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