SURAT PERMOHONAN CUTI

REQUEST OF LEAVE FORM

Yang bertanda tangan dibawah ini/ The undersigned:

Nama/ Name :
Divisi/Bagian/ Division/Section :
Jabatan/ Position :
Tgl. Mulai Bekerja/ Start Working Date :

Mohon diizinkan untuk mengambil cuti pada tanggal / Request for taking leave on:

Jumlah hari / Number of days :

Alasan Cuti / Reason for taking leave :[ ] Cuti Tahunan / Annual Leave
[ ] Melahirkan / Maternity Leave
[ ] Cuti tanpa dibayar / Leave without Pay
[ ] Lainnya / Other ( jelaskan/explain):

Selama cuti anda dapat dihubungi / : Telephone

While on leave you can be contacted
Handphone/Mobilephone

Selama cuti pekerjaan dilimpahkan kepada / During my absence, my work will be delegated to:
1. Nama/Name :
2. Nama/Name :
Bagian/Sec. :
Bagian/Sec. :
Ttd/Signature :……………………….......…………
Ttd/Signature :……………………….......…………

* Kepala Divisi (Atasan yang bersangkutan) harus memastikan bahwa cuti yang diajukan oleh
karyawan tidak mengganggu aktifitas produksi dan operasional pada divisi yang bersangkutan. /
*Head of Division (Superior of the employee concerned) shall ensure that the leave requested by the
employee will not interfere production and operational activities in related division.

Jakarta ,

Yang Mengajukan * Menyetujui Mengetahui

Requested by * Approved by Acknowledged by

Karyawan / Atasan Langsung / Manajer HRD dan Umum

Employee Direct Superior HCM & GA Manager
Tembusan / CC: 1. Divisi HCM / HCM Division 1 of 2
 SURAT PERMOHONAN CUTI
REQUEST OF LEAVE FORM
*) Coret yang tidak perlu / strike out whichever is not applicable

Tembusan / CC: 1. Divisi HCM / HCM Division 2 of 2

 Diisi oleh HRD / Filled by HRD

Catatan/ Notes:
1. - Jatah cuti tahunan/Annual leave allocation : ……… hari/day(s)
- Cuti yang telah diambil/Leave taken : ……… hari/day(s) (tgl./date..........................................)
- Cuti bersama yang telah diambil/Public leave taken : ……… hari/day(s) (tgl./date..........................................)
- Sisa cuti yang masih ada/Remaining leave.........................................hari/day(s)
- Rencana pengambilan cuti/Plan of taking leave : ……… hari/day(s) (tgl./date..........................................)
☐ Termasuk cuti bersama/
Including public holiday..........................hari / day(s)
- Sisa cuti yang masih ada/Remaining leave.........................................hari/day(s)
- Rencana cuti bersama yang masih ada/
Plan of remaining public leave..........................................................hari/day(s)
2. Permohonan cuti (beri tanda ) / Leave request (tick ) :
☐ Sudah sesuai rencana cuti tahunan / is already in accordance with annual leave plan
☐ Disetujui Atasan Langsung / Approved by Direct Superior
☐ Diundur ke tanggal/ Postponed to :....................................... s.d tanggal/ until date :.......................................
☐ Mengingat kepadatan pekerjaan cuti fisik diganti dengan uang / Concerning the work density, physical leave will be
paid by money
3. Telah dilampirkan uraian pekerjaan yang pending kepada karyawan pengganti / Enclosed the pending job description to
the delegated replacement employee.
4. Cuti yang melebihi 3 hari, PIN, password, dan access card harus disable (kecuali ada izin khusus dari direktur operasi) /
PIN, password and access card for employee taking leave more than 3 days will be disabled. (except, there is a special
permission from Operational Director).
5. Notification email karyawan yang cuti telah diaktifkan./ Email notification of employee who takes leave has been
activated.
6. Kunci2 termasuk nomor kombinasi telah diserah terimakan./ Keys including combination number have been handed
over.