This section captures your current employment details and establishes baseline information for your remote work request. Please ensure all information is accurate and up-to-date.
Employee ID Number
Full Legal Name
Corporate Email Address
Direct Phone Number
Current Job Title
Primary Department/Business Unit
Current Direct Manager Name
Original Hire Date with Company
Start Date in Current Role
Current Employment Classification
Full-Time Regular
Part-Time Regular
Fixed-Term Contract
Contingent Worker
Current Primary Work Location (Office Name)
Current Work Address
Most Recent Performance Rating (1=Poor to 5=Exceptional)
Total Years of Service with Company
Are you currently participating in any remote or hybrid work arrangement?
Detailed Reason for Requesting Permanent Remote Work Arrangement
Is this request for a permanent arrangement (indefinite duration)?
Proposed Effective Start Date for Remote Arrangement
Provide comprehensive details about your proposed remote work location and your strategic plan for managing time zone differences, maintaining team collaboration, and ensuring business continuity.
Target Remote Work Country
Target State/Province/Region
Target City
Full Physical Address of Proposed Remote Work Location
Location Classification
Domestic (Same Country, Different State/Province)
International (Different Country)
Time Zone of Target Location (relative to UTC)
Time Zone Difference from Primary Company Headquarters (in hours)
Proposed Daily Core Working Hours (Start Time in Target Location)
Proposed Daily Core Working Hours (End Time in Target Location)
Will you maintain flexible availability to accommodate cross-time-zone meetings with your primary team?
Detailed Collaboration & Communication Strategy
Business Justification for Specific Location Choice
Will this location change impact your ability to serve key clients or customers in their preferred time zones?
Estimated Frequency of In-Person Visits to Primary Work Location
Monthly
Quarterly
Semi-Annually
Annually
As needed for critical business events
Not required
Can you commit to being available for emergency on-site work with reasonable notice (e.g., 48-72 hours)?
Contingency Plan for Power, Internet, or Infrastructure Outages
This critical section assesses potential tax, payroll, and legal implications for both you and the company. Your responses will trigger reviews by Legal, HR, and Finance teams. Incomplete or inaccurate information may result in denial or delays.
Primary Tax Residency Status During Remote Work
I will remain tax resident in my current jurisdiction
I will become tax resident in the target remote location
I will be tax resident in a third jurisdiction
Uncertain/Require guidance
Do you understand that your compensation may be adjusted based on local market conditions, cost of living, or currency fluctuations in the target location?
Could your presence in the target location create a 'permanent establishment' risk for the company, potentially triggering corporate tax obligations?
Which payroll and benefits considerations apply to your situation? (Select all that apply)
Potential change in social security/national insurance contributions
Health insurance coverage portability concerns
Retirement plan/pension contribution eligibility changes
Stock options/equity grant tax treatment changes
Workers compensation insurance jurisdiction questions
Paid time off/holiday entitlement differences
None of the above
If international relocation, do you currently possess valid work authorization for the target country?
Legal & Compliance Risk Self-Assessment
Strongly Disagree | Disagree | Neutral | Agree | Strongly Agree | |
|---|---|---|---|---|---|
I understand the local labor laws of my target location | |||||
I am aware of data privacy regulations that may apply (e.g., cross-border data transfer restrictions) | |||||
I comprehend the implications for intellectual property rights in the target jurisdiction | |||||
I acknowledge potential conflicts of interest if working for other employers locally | |||||
I understand the company's right to modify or terminate this arrangement based on legal risk |
Social Security/National Insurance Coverage Plan
Continue in home country system via bilateral agreement
Enroll in target location system, cease home country contributions
Maintain dual coverage where legally permissible
Require HR guidance to determine
Will you maintain a valid address and bank account in your current jurisdiction for payroll purposes if required?
Additional Legal or Compliance Considerations
Have you consulted with legal counsel regarding any contractual obligations or restrictions that may affect this arrangement?
Earliest Date Legal & Tax Clearance Can Be Completed
Your remote work environment must meet stringent IT security standards to protect company data and maintain operational integrity. This section evaluates your technical readiness and security posture.
Primary Internet Service Provider (ISP) at Target Location
Download Speed (Mbps)
Upload Speed (Mbps)
Internet Reliability Rating (1=Unreliable, 5=Extremely Reliable)
Do you have a backup internet connection (e.g., mobile hotspot, secondary ISP)?
Can you establish a stable VPN connection to company networks?
Primary Work Device Setup
Company-issued laptop only
Company-issued desktop only
Personal device with company remote desktop
Hybrid (company laptop + personal peripherals)
Require new company equipment
Will your workspace be in a physically secure location (private room with lockable door)?
IT Security & Data Protection Self-Assessment
Strongly Disagree | Disagree | Neutral | Agree | Strongly Agree | |
|---|---|---|---|---|---|
I will use company-approved antivirus and endpoint protection software | |||||
I will encrypt sensitive data on all devices | |||||
I will lock devices when unattended | |||||
I will avoid public Wi-Fi for company work without VPN | |||||
I will report security incidents immediately | |||||
I will not allow unauthorized individuals to access company systems | |||||
I will adhere to data classification and handling policies |
Will you have access to a local IT support provider or technician if hardware issues arise?
Critical Business Applications & Tools Access Requirements (Select all that apply)
Video conferencing (Zoom, Teams)
VPN access
Cloud storage (OneDrive, SharePoint)
CRM systems
Financial systems
Development environments
Customer support platforms
Project management tools
Specialized departmental software
None of the above
Does the target location have data sovereignty laws that may restrict cross-border data transfers?
Incident Response & Communication Plan
I acknowledge that I have read, understood, and will comply with the company's Remote Work IT Security Policy, Data Protection Policy, and Acceptable Use Policy.
This final section is to be completed by your direct manager, department head, and HR leadership. It captures formal assessments, risk approvals, and authorization signatures required to implement the remote work arrangement.
Manager Name
Manager Title
Manager Assessment: Role Suitability for Remote Work (1=Not Suitable, 5=Highly Suitable)
Manager Assessment: Impact on Team & Operations
Strongly Disagree | Disagree | Neutral | Agree | Strongly Agree | |
|---|---|---|---|---|---|
Employee can perform core job functions remotely without degradation | |||||
Team collaboration and morale will be maintained | |||||
Knowledge transfer and mentorship capabilities are preserved | |||||
Client/customer service levels will not be negatively impacted | |||||
Decision-making speed and quality will be sustained | |||||
Emergency response and availability can be managed |
Manager Comments on Productivity & Performance Monitoring Plan
Cost Impact Analysis (to be completed by Manager & Finance)
Cost Category | Estimated Annual Cost Increase | Estimated Annual Cost Savings | Explanation/Justification | |
|---|---|---|---|---|
Travel to primary office location | $0.00 | $0.00 | Enter estimated flights, hotels, ground transport | |
IT equipment & software licenses | $0.00 | $0.00 | Enter costs for VPN, security tools, hardware | |
Home office stipend/allowance | $0.00 | $0.00 | Enter recurring monthly/annual stipend | |
Telecom & internet reimbursement | $0.00 | $0.00 | Enter expected reimbursement amounts | |
Co-working space membership (if applicable) | $0.00 | $0.00 | Enter fees for external workspace | |
Reduced office space footprint | $0.00 | $0.00 | Enter savings from freed desk space | |
Other miscellaneous costs | $0.00 | $0.00 | Specify any other cost impacts | |
Does this arrangement require a trial period before permanent approval?
Department Head Conditions or Contingencies for Approval
Department Head Approval: I have reviewed this request, assessed operational impact, and support this remote work arrangement subject to HR, Legal, and IT risk clearance.
Department Head Digital Signature
Department Head Approval Date
HR Director Approval: HR has reviewed compliance with employment laws, compensation implications, and policy alignment. All mandatory checks completed.
HR Director Digital Signature
HR Director Approval Date
Legal Counsel Clearance: Legal has assessed permanent establishment risk, immigration compliance, and contractual amendments. No material legal impediments identified.
Legal Counsel Digital Signature
Legal Clearance Date
CIO/IT Security Approval: IT has verified security measures, connectivity standards, and data protection protocols. Remote access authorized.
CIO/IT Security Officer Digital Signature
IT Security Approval Date
Final Arrangement Terms & Conditions