If Faxing please ensure Employee’s Name and Personnel Number are included on each page of the form
Name ____________________________ Personnel No._______________________
HR 115_V3 Nov 2015 Revised 03/11/2015
Page 2 of
Declaration
1. I declare that all information given by me in this application is true and complete.
2. I understand that my acceptance of the shorter working year scheme is subject to the terms outlined in
circular 023/2015.
3. I undertake that any overpayment which may arise from my participation in this Scheme will be repaid to
the HSE No later than 31
st
December of the year the special leave is taken
4.
I understand that this leave must be used for the purpose for which it is being sought
Signature Date
Section 2. To be completed by the Line Manager
Special Leave Recommended
Yes No
Signature Date
Name: Grade
Contact Phone No: Mobile No:
E-mail Address
Section 3. Senior Management Approval
Special Leave Approved
Yes No
Signature Date
Name: Grade
Contact Phone No: Mobile No:
E-mail Address
Comments (if application is refused, state why)
Important: If the application is approved this form must be returned to HR by 30
November.
Section 4. Delegated Officer Approval
Name (Print) Signature
Tel No Date
Decision No
Section 4. To be completed by Human Resources, Personnel Administration
Is Employee in receipt of interim payment?
Yes No
If yes has Payroll been notified to cease interim payment
Yes No
Date payroll notified to cease interim payment
System updated by Date
Payroll Notified to set up averaged pay Date
