Atlantic Pilotage Authority
APPLICATION FOR LEAVE
To be completed by applicant.
Last or Family Name (In block letters) First Name and Initials
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Start Time:
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From
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End Time:
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To
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Period Requested
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__________
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_____________
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_________
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_____________
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Day/Month/Year
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Day/Month/Year
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Location
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Signature
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Date
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| Type of Leave
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No. of Working Days
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No. of Working Days
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Sick Leave with Medical Certificate
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Special
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Sick Leave without Medical Certificate (not exceeding 3 days)
Nature of Uncertified Illness
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Other (Specify):
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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
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Signature of Employee
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When special leave is requested, give reasons:
To be completed by Administration Manager
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Date
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Authorizing Signature
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Remarks:
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