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Maternity Leave Certificate Form

This document is a maternity leave certificate that must be submitted with an application for maternity leave. It requires information about the applicant such as their name, department, expected delivery date as certified by a medical practitioner. The applicant also agrees to refund the government if they do not return to work after the 90 day maternity leave period. They must disclose if they have taken previous paid maternity leaves.

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Mckleen Jeff Onil Aroco
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21K views1 page

Maternity Leave Certificate Form

This document is a maternity leave certificate that must be submitted with an application for maternity leave. It requires information about the applicant such as their name, department, expected delivery date as certified by a medical practitioner. The applicant also agrees to refund the government if they do not return to work after the 90 day maternity leave period. They must disclose if they have taken previous paid maternity leaves.

Uploaded by

Mckleen Jeff Onil Aroco
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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MATERNITY LEAVE CERTIFICATE

(To be submitted together with the “Application for Leave Form” which shall be clearly
marked “Maternity Leave” in the top right hand corner).

NAME:....................................................................... E.C. No. ...........................................

DEPT/STATION CODE.....................................................................................................

SECTION/SUB-SECTION ................................................................................................

PART I

Certificate by Registered Medical Practitioner or Government Clinical Officer

I certify that ............................................................................................................................is


pregnant and that the expected date of delivery is ................................................................

............................................................................(Signature – Registered Medical Practitioner/


Government Clinical Officer)

...........................................................................(Name in block letters – Registered Medical


Practitioner/Government Clinical Officer* and qualifications)

* Delete inapplicable

N.B. A Government Clinical Officer complete this certificate if there is no Medical


Practitioner stationed in the rural area where the woman works.

PART II (To be completed by applicant)

I agree to refund to Government in full the amount paid to me in consideration of the grant of
90 days maternity leave on 75% basic salary should I fail to resume duty on expiry of the
maternity leave.

(delete inapplicable)

I certify that i have not been granted paid leave previously whilst in Government service:

OR

I certify that I have been granted paid maternity leave........... times previously whilst in
Government Service.

.................................................................................................(Signature of applicant)

.................................................................................................(Witness)

.................................................................................................(Date)

FAILURE TO GIVE THE CORRECT INFORMATION MAY RESULT IN THE


APPLICANT’S DISCHARGE FROM THE SERVICE.

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