Flexible Working Application Form



Note to the employee

You can use this form to make an application to work flexibly under the right provided in law to help eligible employees care for their children.


You should note that under this right it may take up to 14 weeks to consider a request before it can be implemented and possibly longer where difficulties arise. You should therefore ensure that you submit your application to the appropriate person well in advance of the date you wish the request to take effect.


It will help your employer to consider your request if you provide as much information as you can about your desired working pattern. It is important that you complete all the questions as otherwise your application may not be valid. When completing sections 3 & 4, think about what effect your change in working pattern will have both on the work that you do and on your colleagues. Once you have completed the form, you should immediately forward it to your employer (you might want to keep a copy for your own records). Your employer will then have 28 days after the day your application is received in which to arrange a meeting with you to discuss your request. If the request is granted, this will be a permanent change to your terms and conditions unless otherwise agreed.


Note to the employer

This is a formal application made under the legal right to apply for flexible working and the duty on employers to consider applications seriously. You have 28 days after the day you received this application in which to either agree to the request or arrange a meeting with your employee to discuss their request. You should confirm receipt of this application using the attached confirmation slip.


1. Personal details
Name: Staff or payroll no:
Manager: National Insurance no:


To the employer

I would like to apply to work a flexible working pattern that is different to my current working pattern under my right provided in law. I confirm I meet each of the eligibility criteria as follows:


  • I have responsibility for the upbringing of either a child under six or a disabled child under 18.
  • I am:
    • the mother, father, adopter, guardian or foster parent of the child; or
    • married to or the partner of the child’s mother, father, adopter, guardian or foster parent.
  • I am making this request to help me care for the child.
  • I am making this request no later than two weeks before the child’s sixth birthday or 18th birthday where disabled.
  • I have worked continuously as an employee of the company for the last 26 weeks.
  • I have not made a request to work flexibly under this right during the past 12 months.


If you are unable to tick all of the boxes then you do not qualify to make a request to work flexibly in law. This does not mean that your request may not be considered, but you will have to explore this separately with your employer. Many employers offer flexible working to their staff as best practice.


2a. Describe your current working pattern (days/hours/times worked):
2b. Describe the working pattern you would like to work in future (days/hours/times worked):







(you may continue on a separate sheet if necessary)

2c. I would like this working pattern to commence from: Date:


3. Impact of the new working pattern
I think this change in my working pattern will affect my employer and colleagues as follows:










4. Accommodating the new working pattern
I think the effect on my employer and colleagues can be dealt with as follows:









Name: Date:







Cut this slip off and return it to your employee in order to confirm your receipt of their application.


Employer’s Confirmation of Receipt (to be completed and returned to employee)
I confirm that I have received your request to change your work pattern on: Date:
I shall be arranging a meeting to discuss your application within 28 days following this date. In the meantime you might want to consider whether you would like a fellow colleague to accompany you at the meeting.