Leave Request Form

Your Name

Your Email Address

Your IRD Number

Type of Leave Requested Annual Leave Sick Leave ACC Leave (1st Week, 80%) Bereavement Leave Family Violence Leave Parental Leave Unpaid Leave

Days Requested (Note: Where leave is requested in "weeks", the formula used to determine a week is dependant upon your pattern of work. If you have a pattern of only having worked an average of 4.5 days a week in the last 8 weeks, then you will be apportioned 4.5 days for each week of leave you take.) 1 Half Day 1 Full Day 2 Days 3 Days 4 Days 5 Days 6 Days 1 Week 2 Weeks 3 Weeks 1 Month More than a month

Leave Start Date

Request and Declaration (You cannot change this field!) Please see my leave request! "I understand that apportioning of leave is dependant upon my pattern of work in the last 8 weeks, and will be determined based on the averages calculated."

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