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6P-s. oss TPH 103 ( @Q510351 OL Css HOSPITAAL PaSIENT Wo. . C6 2E°E., MryMrs/Miss Peer Ble. bo on r./Mev./Mej was attended to at this insti was in hierdie inrigting behandel op suttering from iydende aan......... ACU cer? yer oF dar gewone pligte te hervat op. .dical Otficer/Geneesheer Medica 2seunszy Coane Know ye ONE Wore snr : ; a Cun3 CLAD Dorey SuAY WMN3y k fe a!—-a ai ts. s 2g 22\95) 227y P Bnigstampy Oe ) > & zo # Bee 704 « £ ir\ir om 4 ip ig e889 12 iD EC So § His of% iy i/i) Sa 3 Lo D a an \i 3] y Scheduled Appointment g 8 LEAVE APPLICATION FORM qa Applicant's Name & Sumame & Clock umber, __\%_C,otheine _ x Posionib ite & @ king ws Return to work (9 Type ot eave) From first day of leave: To last day of leave: date: | make SF heal @ : 33u : Skt Siete IR Dap 29-27-2020 [SAD-D4y | Family Responsibility ** Maternity sudy npaa= Total no of days applied for / taken: * Inthe case of Sick Leave a Registered Medical Practitioner's Certificate must be attached “In the case of Family Responsibility Leave the relevant proof must be attached State detailed reasons for applying for unpaid leave Applicant's physical Address whilst on leave: Sek Aeplean siepronetonadre: Oe GSS SD LU Applicant's signature: Sc Crouse paw 2 DY FOR OFFICE USE ONLY Approved © / Declined G1 Name: Signature: Leave credit: Family responsibil Annual Maternity Opening balance: Number of days taken: New Balance:

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