LEAVE FORM

Name: Pembrimen Saragih Amendment: YES NO

(Please refer to Note 3 below)

Date: 16/12/2016

FIRST WORKDAY LAST WORKDAY TOTAL NO. OF

OF LEAVE OF LEAVE WORKDAYS
TYPE OF LEAVE (Day/Mth/Yr) (Day/Mth/Yr) LEAVE

Annual Leave 27/12/2016 02/01/2017 5

Public Holidays
(Please refer to Note 1 below)

Special Leave Paid

Special Leave Unpaid

Sick Leave
(Please refer to Note 2 below)

Amendment
(Please refer to Note 3 below)

TOTAL 5

If Sick/Special leave please give reasons

Notes:
1.Leave forms are not required for public holidays unless they fall within a leave period outlined above.
2.If a sickness absence is greater than two (2) days a Doctors Certificate needs to be provided.
3.Should you need to amend any leave previously requested, please submit a new leave form. Please advise the
dates previously requested in the Amendment part of the form.
4.A minimum of 4 weeks leave taken and 4 weeks notice is required for advance payment.
5.Please send form to Office Administrator.

Employee Signature: Date: 16/12/2016

Pembrimen Saragih
Approved: Date:

Issue:21-06-10 F-HR-5_Leave Form Page 1 of 1