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Appendix A

Record of Requests for Flexible Working (to be kept on individual’s personal file and a copy forwarded to the HR Representative)

Name:

Position:

Hours of Work:

Place of Work:

Date of Joining:

Date of Request for Flexible Working:

Date of Meeting to discuss Flexible Working and names of who present:

Date of letter confirming decision and brief explanation for decision (a copy of the letter detailing fully the reason should also be kept on their file)

Date of any Appeal lodged:

Date of Resolution to any Appeal:

Date at which applicant eligible to re-apply (not less than 12 months after first request declined):

Signed: (line manager) …………………………………………………………….

Name: (in block capitals) …………………………………………………………

Department: (in block capitals) ……………………………………………………

Flexible Working and Flexi-Time Policy Version 2

Page 7 of 7

January 2011

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