HTML version of the form: Application For Pre-Retirement Transition Leave

Protected when completed

Information on this form is used to assess requests for Pre-retirement Transition Leave in accordance with approved policies. It is protected by the provisions of the Privacy Act and should be stored in standard employee bank PSE 901.

Part I - Employee Data

• Surname (Print):
• Given name / Initials:
• Personal Record Identifier:
• Department:
• Branch / Division / Section:
• Address:

Part II - Application

• Duration of leave arrangement (max. 2 years):
  • From:
  • To:

Leave Period

(insert amount) day / week or (insert amount) hours / week if non-standard

Please indicate days to be taken off:

I request a leave arrangement in accordance with the Pre-retirement Transition Leave Policy.

I agree not to work for the federal Public Service during the above period of leave.’é

I understand that, once accepted by the deputy head or his or her delegated authority and once my leave arrangement is completed, my resignation is irrevocable.

I resign effective (insert Day/Month/Year) conditional upon my leave arrangement not being cancelled prior to the dates agreed to above.

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

Employee signature:

Part III - Approval

• Leave Arrangement Approved
  • From:
  • To:
  • I certify that the employee meets the eligibility criteria
• Leave Arrangement Not Approved
  • for the following reasons:

• Responsibility Centre Manager (print name):
• Responsibility Centre Manager (signature):
• Date
  • Day:
  • Month:
  • Year:

Part IV - Acceptance of Resignation

• I accept your conditional resignation upon completion of the leave arrangement as agreed to above.:
• Signature of Deputy Head or Delegated Authority:
• Date
  • Day:
  • Month:
  • Year:

Once completed, provide employee with a photocopy

TBS/SCT 325-9E (Rev. 1999-05-18)