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APPLICATION TO BE ILL

(This form must be submitted at least 21 days before the date on which you wish illness to commence.)

NAME ................................................ EMPLOYEE NUMBER.............................

DEPARTMENT .................................................... GRADE ...............................

NATURE OF ILLNESS ............................................................................

DATE ON WHICH ILLNESS TO COMMENCE ............................................................................

(Applications to suffer from pregnancy must be submitted 12 months prior, and accompanied by form no. WS.36/24/36.)

DO YOU HAVE THE CONSENT OF YOUR HUSBAND / WIFE / PARTNER / FLATMATES / PARENT(S)? YES/NO

HAVE YOU EVER APPLIED TO SUFFER FROM THIS ILLNESS BEFORE? YES/NO

IF YES, PLEASE GIVE DATE(S) ............................................................................

DO YOU WISH ILLNESS TO BE SLIGHT/SEVERE/CRIPPLING/FATAL/OTHER

DO YOU WISH THE ILLNESS TO BE INTERMITTENT, TEMPORARY OR PERMANENT .................................................

IF INTERMITTENT OR TEMPORARY, PLEASE STATE THE PREFERRED DURATION(S)
................................................
(No guarantee can be given regarding the duration, other than in the case of fatal illness, but management will endeavour to meet all requests where possible).

DO YOU WISH TO SUFFER THIS ILLNESS AT HOME / HOSPITAL / COSTA BRAVA / BOGNOR REGIS / SALTCOATS / TYNECASTLE / HAMPDEN PARK / MURRAYFIELD / OTHER ................................................................

DO YOU WISH THIS ILLNESS TO BE OF A CONTAGIOUS NATURE YES/NO

IF YES, INDICATE APPROXIMATE NUMBER OF PEOPLE YOU WISH TO INFECT
..........................................................

PLEASE STATE HERE ANYONE YOU PARTICULARLY WISH TO INFECT
.........................................................................
(No guarantee can be given regarding infection of individuals, but management will endeavour to fulfil requests wherever reasonable.)

HAVE YOU EVER BEEN REFUSED PERMISSION TO SUFFER FROM AN ILLNESS, IF YES,
PLEASE GIVE DETAILS

...........................................................................................................................................

DO YOU WISH YOUR WIFE / HUSBAND / PARTNER / FAMILY / FLATMATES / COLLEAGUES TO BE INFORMED OF YOUR ILLNESS IF SHE / HE / THEY SHOULD MAKE ENQUIRIES REGARDING YOUR WHEREABOUTS? YES/NO

I, the undersigned, do hereby declare that to the best of my knowledge, the answers given above are true and accurate.

Signed ..............................................................
Date ................................................................

Applicants are reminded that all requests are considered on merit and more than three applications per annum will be considered excessive and not in the best interests of the department. Applicants are further reminded that malicious infection of the Sick Leave Committee may affect the prospects of future applications. Under NO CIRCUMSTANCES will permission be given for more than one fatal illness per applicant.

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