Maternity Leave Application Form Template
This form is to be used by employees to apply for Maternity Leave or additional Maternity Leave. Please give a minimum of four weeks notice to your employer before taking Maternity Leave.
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Work Email
example@example.com
Department
Title
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employee ID
Maternity Leave Details
Expected Date of Birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Maternity Leave
Please check if you intend to take ordinary maternity leave
Please check if you intend to use additional maternity leave (unpaid)
Maternity Leave Start Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
End Date (Up to 14 weeks)
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Additional Leave Start Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
End Date (Up to 4 weeks)
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
I intend to get back to work in
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please upload document(s) supporting your request
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please sign here
Submit Application
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