Missing Service

Service Confirmation Form

EMPLOYER DETAILS
LeavePlus Employer Member Number*
Registered Business Name*
Trading As*
ABN*
ACN
AUTHORISING MEMBER
Authorising Member Type*
Authorising Member Name*
First name Surname
Email Address*
Telephone Number*
WORKER DETAILS
LeavePlus Member Number*
Worker Name*
First name Surname
Worker Type*
Industry Type*
Main trade
Main trade
Main trade
WORKER SERVICE DETAILS

Days and Wages Information

Financial Year	Days worked	Wages	Actions

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Days and Wages Information

Financial Year	Days worked	Actions

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DECLARATION
Consent*
I declare that, to the best of my knowledge, all the information I have provided is true and correct. I authorise LeavePlus to use the provided information for its intended use.*
Declaration Date
DD slash MM slash YYYY