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ANNEXURE A APPLICATION FORM: TEMPORARY INCAPACITY …

CONFIDENTIAL APPLICATON FORM TEMPORARY INCAPACITY LEAVE SHORT PERIOD CONFIDENTIAL 1 ANNEXURE A APPLICATION FORM: TEMPORARY INCAPACITY LEAVE SHORT PERIODS IMPORTANT 1 This APPLICATION form must be completed in respect of an INCAPACITY leave period of less than 30 working days. 2 This form comprises six parts, Parts A to F. The employee must complete Parts A and B. Parts C to F are for official use only. 3 Please ensure that this form is duly completed, signed and accompanied by all the required supporting documents, as missing or omitted information will delay finalisation of the APPLICATION . Please also refer to the Determination on Leave of Absence for the requirements in respect of medical certificates.

Eastern Cape Provincial Administration Limpopo Provincial Administration Free State Provincial Administration North West Provincial Administration Gauteng Provincial Administration KwaZulu-Natal Provincial Administration 2. PARTICULARS ON THE EMPLOYEE Date joined Department / Public Service Job title Full-time / Part-time Annual …

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