TO BE COMPLETED BY EMPLOYEE REQUESTING EMPLOYMENT BREAK
Name:	Click or tap here to enter text.
Department:	Click or tap here to enter text.
Job Title:	Click or tap here to enter text.
Band:	Click or tap here to enter text.	Hours:	Click or tap here to enter text.	Start Date with Trust:	Click or tap to enter a date.
Length of Break Request:	Click or tap here to enter text.
Requested Dates:	Commencement Date:	Click or tap to enter a date.	End Date:	Click or tap to enter a date.
Reason for Employment Break:
Click or tap here to enter text.
I sign to confirm I understand and accept the conditions of the Employment Break Scheme
Signature:	Click or tap here to enter text.	Date:	Click or tap to enter a date.

TO BE COMPLETED BY LINE MANAGER
Do you approve this Employment Break Application	Yes	☐	No	☐
Comments: Click or tap here to enter text.
Commencement Date:	Click or tap to enter a date.	Return Date:	Click or tap to enter a date.
Confirmation letter and change form completed and sent (copy attached)	Yes	☐	No	☐
Signature:	Date:

CONTACT ARRANGEMENTS DURING EMPLOYMENT BREAK
Address:	Click or tap here to enter text.
Post Code:	Click or tap here to enter text.	Email:	Click or tap here to enter text.
Telephone:	Click or tap here to enter text.	Other Telephone:	Click or tap here to enter text.

DIRECTOR / GENERAL MANAGER APPROVAL
Do you approve this Employment Break Application	Yes	☐	No	☐
Signature:	Click or tap here to enter text.	Date:	Click or tap to enter a date.

Please ensure all required letters and forms have been completed if the Employment Break is approved. Copies should be held on the employee’s file