Aanvraagformulier Ouderschapsverlof - TU Delft Medewerkers

14 downloads 115 Views 45KB Size Report
Application form Parental Leave. A. Employee details. Name: Initials: Personnel number: Employment date TU: Do you have a parental relationship with the ...
Application form Parental Leave A. Employee details Name:

Initials:

Personnel number:

Employment date TU:

Do you have a parental relationship with the child? Yes No If no, please send a statement of the municipality stating that you live at the same address as the child and that you have taken responsibility for the child’s long-term care and upbringing. B. Child’s details for which parental leave is requested Name:

First name:

Birthdate:

In regard to this child have you already taken parental leave under this or another employer? If yes, than there is no right for partially paid parental leave for the child for which you have already taken parental leave with another employer. Paid:

No

Yes, for the period …………….. to ……………….

Total hours: …..

Unpaid:

No

Yes, for the period …………….. to ……………….

Total hours: …..

C. Ouderschapsverlof wordt aangevraagd voor Pursuant to the parental leave regulations, you can divide your parental leave in maximum 6 periods, each lasting at least one month. In case you would like to take your leave in multiple periods, please indicate this on your first application. If not, you will loose the remaining leave hours. Paid (maximum 13 times the weekly working hours): Period (A) from: …………………..………

to …….……………………

total hours per week: ……

Period (B) from: …………………..……...

to ……….…………………

total hours per week: ……

Period (C) from: …………………..……...

to ……….…………………

total hours per week: ……

Unpaid (maximum 13 times the weekly working hours): Period (D) from: …………………..……...

to …….……………………

total hours per week: ……

Period (E) from: …………………..……...

to …….……………………

total hours per week: ……

Period (F) from: …………………..……...

to ……….…………………

total hours per week: ……

D. Signature By signing this form you agree with the conditions as set in the regulation “Dutch Universities Parental leave on partial pay scheme, 2007”. Please notice art. 4.13f, sub 5 of above mentioned regulation. In the event you hand in your notice within six months of the end of your partially paid parental leave, or the employment is terminated due to circumstances attributable to you, you shall be obligated to repay the partial remuneration you have received.

Signature employee

Date

Signature manager

Date