PARENTAL LEAVE APPLICATION FORM Page 1 of 1

Date Issued: 01-JUN-2017

HDAL-HR-18-F16 Version: 2.0

Employee name Employee number

Brock Retschlag 00300498
Position Location
Fitter Darwin
Function Section
GR
Parental Leave type requested ☐Pre-Adoption or Pre-Surrogacy Leave

☐Primary Carer’s Leave (includes Adoption Leave or Surrogacy Leave)

☐Secondary
✔ Carer’s Leave

The Parental Leave procedure (HDAL-HR-18-PR04) outlines eligibility and entitlements to the above leave
types.
Parental Leave dates requested Period of Leave

Annual Leave From To

Long Service Leave From To

Pre-Adoption or Pre-Surrogacy From To Two days unpaid

Leave
Primary Carer’s Leave From To  8 weeks paid (full pay)

(select one pay option) From To  16 weeks paid (half pay)

Unpaid Primary Carer’s Leave From To Total period up to 52 weeks

Secondary Carer’s Leave From To One week’s paid

26/02/24 01/03/24
Unpaid Secondary Carer’s From To
Total period up to eight
Leave 04/03/24 08/03/24 weeks
Return to work date
11/03/24
Employee declaration

 For Primary Carer’s Leave, I confirm that I will be the Primary Carer of the child for the duration of the
leave requested.
 I confirm I have read and understood the Parental Leave procedure and agree to the conditions of
eligibility to take leave.
 I agree to advise the Company of any change to my circumstances which would alter my eligibility or
entitlement to Parental Leave.
 I have attached:
o a medical certificate confirming expected date of birth; or
o a letter from the appropriate State (or overseas) authority, confirming that an adoption order and
the expected date of placement; or
o statutory declaration stating that the employee will be the child’s Primary Carer or Secondary
Carer during the period and details of any leave taken by their partner.
Declare any period of leave your partner will be the
Primary Carer of the child.
From
24/02/24 To
12/12/24
Employee signature

Approval
Manager Brad Read Signature Date

Human Signature Date

Resources
Payroll Signature Date
Return this form to: Brisbane Payroll | bnepayroll@hastingsdeering.com.au

Document UNCONTROLLED WHEN PRINTED – Refer to Company Documents for current version