Home Working Application Form

Current Days and Hours of Work:

I wish to apply to be considered for home working and propose the following working arrangements:

Address at which home working would take place:

This application is for a permanent / temporary * period.

*delete as necessary.

If the application is for a temporary period, please state the relevant dates:

Do you feel your home working would have an impact on the service you provide or the colleagues in your team? If so, how could this be minimised?

Home working is not suitable for employees who have caring responsibilities at home during normal working hours. By submitting this application you are confirming that you are not planning to combine home working with caring commitments.

Signed:                                                                                        Date: