Work from home - application form

Applicant’s name
Designation
Mobile no.
Details Address:

Type of application Temporary  Permanent 

Period of application From _____________ to ______________

Suitability checklist (To be completed by both applicant & Superior/Director)

The Work Employee Director

Part of work can be done away from primary workplace 1 2 3 4 1 2 3 4
Requires minimal face to face contact with clients, the
1 2 3 4 1 2 3 4
superior & colleagues
Access to Data, documents, material & resources can be
1 2 3 4 1 2 3 4
arranged
Workflow can be scheduled 1 2 3 4 1 2 3 4
Regular home based work time can be allocated 1 2 3 4 1 2 3 4
Output/outcomes are measurable (qualitative/quantitative) 1 2 3 4 1 2 3 4
The Employee
Is self-motivated 1 2 3 4 1 2 3 4
Show initiative 1 2 3 4 1 2 3 4
Has positive attitude to work& home based working
1 2 3 4 1 2 3 4
objectives/outcomes
can plan & manage a work day 1 2 3 4 1 2 3 4
Can work in isolation 1 2 3 4 1 2 3 4
Can work with minimal face to face supervision & feedback 1 2 3 4 1 2 3 4
Communicates effectively 1 2 3 4 1 2 3 4
Has sufficient job & organisational knowledge 1 2 3 4 1 2 3 4

Applicant’s Signature Date:

Approver’s Signature Date: