Parental Leave Application

Employee Details

Name: [FULL NAME] Job Title: [JOB TITLE] Date of Employment: [START DATE] Work Location: [SITE/OFFICE ADDRESS]

Employer Details

Business Name: [BUSINESS NAME] Supervisor/Manager Name: [MANAGER NAME] Date of Application: [DATE]

Leave Details

Type of Leave: [ ] Unpaid Parental Leave (NES) [ ] Paid Parental Leave (Government funded) [ ] Partner Leave [ ] Adoption Leave

Expected Date of Birth / Placement: [DD/MM/YYYY] Proposed Start Date of Leave: [DD/MM/YYYY] Proposed Return Date: [DD/MM/YYYY]

Declaration

I, [FULL NAME], hereby give notice of my intention to take parental leave.

I confirm that:

1. I am the primary carer of the expected child/child being adopted.
2. I will provide a medical certificate or relevant documentation confirming the expected date of birth or placement.
3. I have read and understood the company policy regarding parental leave.

Return to Work Intention

I intend to return to work on the date specified above. [ ] Yes [ ] No [ ] I wish to request an extension of leave (4 weeks notice required for extension requests).

Employee Signature: __________________________ Date: __________________________

Employer Acknowledgement

I acknowledge receipt of this Parental Leave Application. I accept the proposed leave dates subject to the provision of valid medical evidence.

Manager Signature: __________________________ Date: __________________________

For Office Use Only: [ ] Medical Certificate Received? Yes/No [ ] Dates entered into payroll system? Yes/No [ ] Risk Assessment required? Yes/No