Application to be Ill

This form must be submitted at least 21 days before the date on which
you wish the illness to commence.

Name:
______________________________________________________________
Department:
______________________________________________________________
Date on which you wish the illness to commence: ______________________________________________________________
Nature of illness you wish to suffer from: ______________________________________________________________

(Applications to suffer from pregnancy must be accompanied by form
307/02 with consent of Husband/Wife)

Have you ever applied to suffer from this illness before? ______________________________________________________________
If yes give date:
______________________________________________________________
Do you wish illness to be Slight/Severe/Crippling/Fatal? ______________________________________________________________
If illness is fatal, do you wish this to be considered a permanent disability? ______________________________________________________________
Do you wish this illness to be at Home/Hospital/Abroad? ______________________________________________________________
Do you wish this illness to be of a contagious nature? ______________________________________________________________
If so, indicate the number of people you wish to infect: ______________________________________________________________
Have you ever been refused permission to suffer from an illness? ______________________________________________________________
If so, give details: ______________________________________________________________
______________________________________________________________

I the undersigned declare that to the best of my knowledge the answers
above are true and accurate.

Signed: ________________________________ Date: ________________

Applicants are reminded that all applications will be considered on merit
and that more than three applications per year will be considered
excessive and not in the best interests of the company.
Under No Circumstances will any employee be permitted to suffer from
more than one fatal illness - any person disregarding this warning will
render themselves liable to dismissal.