REGISTER OF MATERNITY LEAVE AND

ALLOWANCES (1C)

Serial Number of

Claim ..................

(EMPLOYMENT ACT 1955)

(Section 44)

Place of employment...........................................................................................

PART A

(To be completed in respect of a female employee about to leave her employment

who reports that she knows or has reason to believe that she will be confined

within a period of four months from the date on which she leaves her employ-
ment).

1. Name and National Registration Identification Card Number........................
2. Future address..............................................................................................
3. Date of leaving employment.........................................................................
4. Date of notifying pregnancy .........................................................................
5. Expected date of confinement.......................................................................
6. Name, National Registration Identification Card Number and address of

nominee (if any) appointed to receive maternity allowance under the provi-

sion of section 41 ..........................................................................................
7. Number of days employed during the

1st .............................. 2nd ............................... 3rd ................................

4th.............................. 5th ................................ 6th ................................

7th.............................. 8th ................................ 9th ................................

month preceding her departure.

PARTB

(To be completed in respect of maternity leave and allowances under the provi-
sions of section 37).
1. Name and National Registration Identification Card Number........................

2. Name, National Registration Identification Card Number and address of

nominee (if any) ......................................................
3. Date of notifying commencement of maternity leave ....................................
4. Date on which employee commenced her maternity leave ............................
5. Number of days employed during the

1st.............................. 2nd ............................... 3rd................................

4th.............................. 5th ................................ 6th ................................

7th.............................. 8th ................................ 9th ................................

month preceding confinement.
6. Date of confinement....................................................................................

7. Date of notifying confinement.....................................................................

8. Date on which work was resumed (or date of leaving the employment or date

of death)........................................

9. Number of consecutive days employee was on maternity leave:

(i) Prior to confinement .........................................................

(ii) After confinement............................................

10. Ordinary rate of pay of employee per day......................................................

11. Amount of maternity allowance and date of payment:

(i) Before confinement ... ... $....................................................

(ii) After confinement ... ... $....................................................

12. If maternity allowance is not paid or not paid in full, state here the reasons ....

I confirm that the above particulars are correct.

Signature of Employer

I confirm that the amounts stated above have been paid to me.

Signature of Employee/Nominee