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A SICK PAY CLAIM FORM FOR ABSENCE FROM WORK DUE TO SICKNESS OR INJURY (NOT INJURY ON DUTY) IN EXCESS OF PAID SICK LEAVE ENTITLEMENT UNDER AN INDUSTRIAL AGREEMENT TO BE COMPLETED BY THE EMPLOYEE Surname Date of Birth First Names Tel No I.D. Number Marital Status Income Tax Reference No Revenue Office Residential Address Postal Code Trade Union of which a Member Membership No Period for which Sick Pay is claimed: From To inclusive IN CASES OF INJURY, STATE Date of injury NOTE Caus.

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