Instructions: Be sure to enter all necessary information



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Date conversion11.02.2018
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Atlantic Pilotage Authority
APPLICATION FOR LEAVE

INSTRUCTIONS: Be sure to enter all necessary information





  1. To be completed by applicant.

Last or Family Name (In block letters) First Name and Initials








Start Time:

From

End Time:

To




Period Requested




__________

_____________

_________

_____________













Day/Month/Year




Day/Month/Year




Location

Signature

Date



























Type of Leave








No. of Working Days




No. of Working Days

Annual Vacation



Sick Leave with Medical Certificate







Special



Sick Leave without Medical Certificate (not exceeding 3 days)


Nature of Uncertified Illness








Other (Specify):







I certify on my honour that I was ill and unable to perform the duties of my position during the entire period of absence for which leave is required











Signature of Employee

When special leave is requested, give reasons:















  1. To be completed by Administration Manager















Date




Authorizing Signature

Remarks:
























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