Sample Form

APPLICATION FORM
FLEXIBLE WORK ARRANGEMENT (FWA)

Application for FWA must be made at least thirty (30) days prior. Application less than thirty (30)
days may be rejected. Please provide supporting documents where applicable.

Employee Details
Name

Employee ID

Mobile Number

Position

Department

Application Date

Emergency Contact Details

Relationship

Mobile Number

Flexible Application Details

Hybrid Work Work From Home Flexible Work Hours

Compressed Week Part-Time Work Others

Reason for application

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

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Sample Form

FWA duration requested

Please describe the work schedule requested

Please describe the work schedule requested

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

To be filled by the applicant

I do not have any disciplinary records for the past twelve (12) months

I met the expected performance level in the most recent assessment period
I agree to meet and comply with the conditions stipulated in the Flexible Work
Arrangement policy as well as any other conditions imposed in the FWA approval letter.

Signature

Remarks (if any)

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Sample Form

Superior/HOD’s acknowledgment

Supported Not supported (please provide justification)

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

For Human Resource use

Approved Rejected

Reason for rejection

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Note : Please notify the application within thirty (30) from the date of the application.

Checklist (please tick where applicable)

Management consent obtained

Superior has been consulted for cases where it is not supported

FWA approval letter/rejection issued

The application understands the conditions of the FWA approved

IT and Security department notified of the FWA details

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This sample form is prepared by the Malaysia HR Forum
https://www.facebook.com/groups/MalaysiaHRForum
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Sample Form

Disclaimer
This sharing by Malaysia HR Forum is for educational and informational purposes only. While the
information in this document has been verified to the best of our abilities, we cannot guarantee that there
are no mistakes or errors. All information is of a general nature and does not address the specific
circumstances of any individual or entity. Nothing in this document constitutes legal, tax, investment,
financial advice and neither is it intended to be a substitute for professional advice. You alone assume
the sole responsibility of evaluating the merits and risks associated with the use of any information or
other content in this document before making any decisions based on such information. By proceeding
further and in exchange for the use of this document, you agree to this disclaimer and shall not to hold
Malaysia HR Forum, the authors and anyone associated with the preparation of this document liable for
any damages, losses or claims arising from any decision you make based on the information or contents
of this document. You are advised to seek guidance further guidance from relevant authorities or
competent authorities when designing your company policy.

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This sample form is prepared by the Malaysia HR Forum
https://www.facebook.com/groups/MalaysiaHRForum
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