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Get Working Form Hse 2015-2024

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 st the HSE No later than 31 December of the year the special leave is taken Signature Date Special Leave Recommended Name Mobile No Section 3. Senior Management Approval Special Leave Approved Comments if application is refused state why Important If the application is approved this form must be returned to HR by 30th November. Section 1. To be completed by the employee I wish to apply for inclusion in the Shorter working Year Scheme in accordance with the terms and conditions set out in Circular 023/2015 Surname First Name Grade Personnel No. Date of Birth PPS No. Correspondence address County Post Code Contact Phone No Mobile Phone No e-mail address Title of Post Work Location Address e.g. Hospital PCCC area I confirm that I have read and understand the terms and conditions as per Circular 023/2015 Yes If this is your first application have you completed one year s continuous service with the HSE Yes No Date of commencement of service Proposed Dates of Special Leave Number of Weeks leave required tick one Special administrative arrangements Averaged Pay Payment Method required tick one Unpaid From To Line Managers Details Address HR 115V3 Nov 2015 Page 1 of 3 Revised 03/11/2015 If Faxing please ensure Employee s Name and Personnel Number are included on each page of the form Name Personnel No. Declaration 1. Shorter Working Year Scheme Application Form HR 115 This form is to be used by employees to apply for Shorter Working Year Scheme Information will be input on the HR /Payroll system for the purposes of Personnel and Payroll Administration* Please complete form in Block Capital/Tick appropriate boxes. 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 st the HSE No later than 31 December of the year the special leave is taken Signature Date Special Leave Recommended Name Mobile No Section 3. Senior Management Approval Special Leave Approved Comments if application is refused state why Important If the application is approved this form must be returned to HR by 30th November. Section 4. Delegated Officer Approval Name Print Tel No Decision No Is Employee in receipt of interim payment If yes has Payroll been notified to cease interim payment Date payroll notified to cease interim payment System updated by Payroll Notified to set up averaged pay Section 5. Payroll Section Phone No Location Code Wage Type Payroll Area Employment Signal Section 7. Circulation List. 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 st the HSE No later than 31 December of the year the special leave is taken Signature Date Special Leave Recommended Name Mobile No Section 3. .

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