
Z1(a)
APPLICATION FOR LEAVE OF ABSENCE
Surname Initials:
PERSAL Number: Shift Worker Yes
No
Casual Employee Yes No
Department
Component
Address During The Leave Period:
Tel. No.:
Type Of Leave Taken As Working Days Start Date End Date Number Of Working Days
Annual Leave
Normal Sick Leave
1
Temporary Incapacity Leave This application form must not be used to apply for temporary incapacity
leave. Temporary incapacity Leave must be applied for on the application
form prescribed in terms of the Management Policy and Procedure on
Incapacity Leave and Ill-health Retirement for Public Service Employees.
Please contact your Personnel Office for further information.
Leave for Occupational Injuries and Diseases
Specify Type of Illness
Adoption Leave
2
Family Responsibility Leave (Provide Evidence)
Special Leave
Specify Type of special leave
Leave For Union Office Bearers (Provide Evidence)
Type Of Leave Taken As Calendar Days/Months Start Date End Date Number Of Calendar Days
Unpaid Leave (Provide motivation)
Maternity Leave (Attach medical certificate) No. of Calendar Months
I hereby certify that the information provided is correct. Any falsification of information in this regard may form ground for disciplinary
action. Furthermore, I full understand that if I do not have sufficient leave credits from my previous or current leave cycle to cover for my
application, my capped leave as at 30 June 2000 will be automatically utilised.
……………………………………………….. ………………………...
EMPLOYEE SIGNATURE DATE
Recommendation By Supervisor/Manager (Mark with X)
Recommended
Not Recommended
Rescheduled
REMARKS (If not recommended please state the reasons & the dates in the case of rescheduling):
…………………………………………………… ………………………….
MANAGER’S/SUPERVISOR’S SIGNATURE DATE
Approval By Head of Department (Mark With X)
Approved With Full Pay
Approved Without Pay
Not Approved
REMARKS (If approved with a change in condition of payment or not approved, please provide motivation):
……………………………………….. ……………………………….
SIGNATURE OF HOD OR DESIGNEE DATE
DATA CAPTURING
CAPTURED BY:…………………………………… CAPTURED ON:……………………………
CHECKED BY:……………………………………. CHECKED ON:…………………………….
1
Applications in respect of sick leave of three or more days must be accompanied by a medical certificate issued by a registered medical
practitioner.
2
Applications for adoption leaves must be accompanied by a declaration on how the entitlement will be used in the case where both spouses
are in the employ of the Public Service.