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: ________________________________________________________
 ____________________________________________________________________________
Do you wish your Wife/Husband to be informed of this illness? _______________

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.