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.