Application for Self-Funded Leave

Part I - Employee Data

• Surname:
• Given name:
• Initials:
• Mailing address:
• Postal code:
• Telephone number (home):

Part II - Employment Data

• Department:
• Branch:
• Division:
• Section:
• Location:
• Job title:
• Group and level:
• Telephone number (work):

Part III - Application

I request leave in accordance with the Terms and Conditions described in the departmental Self-Funded Leave Policy, dated (insert date) which I have read.

• Duration of leave:
• Monthly deduction ($):
• Salary deduction start date:
• Leave start date
  • First choice:
  • Second choice:
  • Third choice:

I agree that her Majesty and her officers or employees shall be in no way responsible for any liability including any charges, costs or unforeseen expenses that I may incur as a result of my participation in the Self-Funded Leave Plan. I further agree that her Majesty shall have no liability whatsoever with respect to the administration and investment of funds in my self-funded leave account.

I acknowledge and agree that this Agreement shall be binding upon all parties and that neither I nor my beneficiaries are permitted to assign any rights under this Agreement.

Dated at (insert location) this (insert day) day of (insert month) year (insert year).

Part IV - Approval

• Leave Approved
  • From:
  • To:
• Leave Not Approved
  • for the following reasons:

• Responsibility Centre Manager (print name):
• Responsibility Centre Manager (signature):
• Date:

• Authorized officer (print name):
• Authorized officer (signature):
• Date:

Part V - Confirmation

• Financial Institution:
• Self-funded leave account no.:
• Custodian (print name):
• Custodian (signature):
• Date:

It is understood that the main purpose of this agreement is to permit the employee to fund, through salary or wage deferrals, a leave of absence from employment; and not to provide benefits on/or after retirement.

TBS/SCT 330-109E (Rev. 1999-05-18)