LEAVE APPLICATION FORM

Employee Name Katleya Mae C.Dorado 3204189

Employee Number
W orkforce Management October 24,2022
Account/Department Date filed
0
Number of Leave Credits
Contact Number 09260031579
______________________________ Remaining __________________________

Inclusive Dates of Leave Application Date of Crediting

Original Schedule
(For HR USE Only)
Day Time Rest Day Start Date End Date Maternity MIB

Monday to 8:00 PM to Saturday & December 19,

Friday 5:00 AM Sunday 2022

Please provide checkmark on the appropriate option

No. of Days Leave
Type of Leave Documents Attached
Provided Category
Medical-related as approved PTO Medical certificate related to hospitalization
Bereavement 7 max PTO Death certificate of deceased family member (indicate relationship)
Original Ultrasound Film
Original Ultrasound Report
Photocopy of 2 valid IDs (affix 3 signatures)
Maternity 60/78 SSS OB History form to be filled out by OB Gyne
Employee Maternity Benefit Acknowledgement Form
SSS MAT1 (Accomplished in BLACK INK)
Print-out of Contributions from SSS website

Paternity 7 annually additional Birth certificate of new born child and Marriage Certificate (2 sets)

Solo-Parent 7 annually additional Photocopy of Valid Solo-parent ID card or certificate(2 sets)

Major Illness
6 to 10 additional Medical certificate related to the illness
Benefit
Special Leave for 60 calendar Operating Room Record, Discharge Summary, Medical Certificate as validated by
Women days the Company Physician
additional

Reason for Leave:

Pregnancy / Delivery
Important Reminders:

• The submission of the leave application form is primarily for the purpose of the benefit approval & implementation
and does not excuse an employee from the call-in procedure.
• This FORM must be fully accomplished, signed by both employee and supervisor, and submitted to Site HR with
complete supporting documents, and officially signed by authorized personnel. Approval of inclusive dates shall be
dependent on the issuance date and the number of days specified in the medical certificate.
• For medical-related leaves:
o HR has the final authority to approve/disapprove leave applications based on company medical guidelines.
o In the absence of PTO credits, the employee may file for SSS Sickness Benefit if the absence is at least for 4
consecutive calendar days. The employee should immediately notify Site HR within 5 calendar days from the start
of the illness by submitting the Sickness Notification Form.

(Print name & Signature)

KATLEYA MAE C.DORADO

__________________________ CLIMSON FORD INSO
__________________________
Employee Supervisor

For HR use only:

HR Approval / Encoding

(Name & Date)

DATA CLASS 3 – HIGHLY CONFIDENTIAL

This document is owned by Teleperformance. This document is for authorized personnel only. Distribution to external parties without
management approval and duly signed confidentiality agreements is prohibited.