Employee No:

Rev
EMPLOYEE LEAVE APPLICATION
02/2019
HR Office Use Only
Leave Balance

HR Signature Date

Full Name

Department Customer Care

No of Days Requested

Day 1 of Leave (Date) Last Day of Leave (Date)

Return to work (Date) Telephone number

Type of leave requested Annual Sick Leave Unpaid Study leave

Family Responsibility Maternity/Adoption Special Leave

Motivation for :
1. Family Responsibility
Leave

2. Special Leave

Signature Employee Date of application

APPROVAL AUTHORITY

Leave Approved Leave Declined Indicate reason below

Designation Designation

Signature Date Signature Date

LEAVE DECLINED

Reason Declined Acknowledgement by employee

 Signature Date

NOSMESA
WERKGEWERSORGANISASIE / EMPLOYERS ORGANISATION