Flexible Work Application Form

The Fair Work Ombudsman requires that requests for flexible work are delivered to the employer in writing to ensure clarity on agreements and adherence to legal requirements.

The template below will help aid employees who wish to request flexible work:

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Flexible Work Application Form
Full name: Click or tap here to enter text.
Date: Click or tap to enter a date.
Job Position Click or tap here to enter text.
Team: Click or tap here to enter text.
Employer Name: Click or tap here to enter text.

Current Work Arrangement

Current Place of Work: Click or tap here to enter text.
Current Days Worked: Click or tap here to enter text.
Current Hours Worked: Click or tap here to enter text.

Proposed Flexible Working Arrangement

Part-time
Working from home
Job Share
Flexi Time
Other: ____________________________
Phased Retirement
I would like the new arrangement to be permanent and start from:(day, month, year) Click or tap to enter a date.
I would like the new arrangement to be temporary:

Start date

Click or tap to enter a date.

End date

Click or tap to enter a date.

Reason for the request: (optional) Click or tap here to enter text.

I believe the proposed arrangement may lead to the following benefits and barriers:

  Benefits Potential Barriers
Myself: Click or tap here to enter text. Click or tap here to enter text.
Business: Click or tap here to enter text. Click or tap here to enter text.
Team: Click or tap here to enter text. Click or tap here to enter text.
Customer: Click or tap here to enter text. Click or tap here to enter text.
I suggest we could fix the potential barriers by: Click or tap here to enter text. Click or tap here to enter text.
Signed: Sign here Sign here
Name: Click or tap here to enter text. Click or tap here to enter text.
Date Click or tap to enter a date. Click or tap to enter a date.