HEAD OFFICE 472 The Esplanade Warners Bay NSW 2282 POSTAL ADDRESS PO Box 1026 Warners Bay NSW 2282 Tel: 02 4948 3362 Fax: 02 4948 6955 Toll Free:1300 852 625 ________________________________________________________________________________________________________________________________ APPLICATION FOR REIMBURSEMENT OF LONG SERVICE LEAVE Company Name: ........................................................................................................ Employer ID………………. Application Number LSL Number Surname, Given Names Date of Birth Number of Hours Hourly Date Leave Award/Negot. Commenced Rate * Bonus Paid (Hourly) * Other Over Total Hourly Award Hourly Total Claimed Rate * Payments * TOTAL CLAIMED I certify that the details shown above are correct and that PAYMENT HAS BEEN MADE to each of the “eligible employees” listed. Name: NOTE: (Please Print)..................................................................... Authorised Officer Signature: ……………………………………………… Date:………..………….. All details requested above need to be provided to ensure that the application for reimbursement can be processed. * = Only Provide to 2 decimal places. Privacy Statement Personal information collected by the Corporation is protected by the Privacy Act 1988. The Corporation's Privacy Policy is available at www.coallslcorp.com.au and sets out the primary purposes for which the Corporation collects, uses and discloses your personal information. The Corporation will not use or disclose your personal information for other purposes unless you consent or it is permitted to do so by the Privacy Act.