Confirmation of eligibility for mobility of persons formerly employed in an excluded position at the Office of the Governor General's Secretary - Request Form

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Privacy Notice Statement

The Public Service Commission (PSC) is committed to protecting the privacy rights of individuals, including safeguarding personal information. The information in this form will be used by the PSC to confirm if you meet the requirements to be eligible to participate in advertised internal appointment processes for a period of one year after ceasing to be employed for at least three years in one or more of the following excluded positions at the Office of the Governor General's Secretary (OGGS) GGS-S-910 to GGS-S-920 - as specified in section 4.1 of the Office of the Governor General's Secretary Regulations. The information provided is protected under the Privacy Act and will be disclosed only in accordance with that Act. It is stored in the PSC Personal Information Bank no. PSC PCE 747 Mobility Provisions for Former Minister's Staff and Persons Formerly Employed at the Office of the Governor General's Secretary. The recorded information will be retained for five years. After two years' retention at the PSC, records are sent to Library and Archives Canada and kept for three years, after which time they are sent to Government Archives Division for historical keeping. For additional information, please consult the INFO SOURCE publication.

PERSONAL INFORMATION

Family name:
Given name:
Home address (including postal code):
Telephone no. (Area code):
E-mail address:

In which official language do you prefer receiving your correspondence?

English [ ]
French [ ]

EMPLOYMENT HISTORY AT THE OFFICE OF THE GOVERNOR GENERAL'S SECRETARY

Please list appointment(s) at the OGGS

Position title:
Excluded position number:
Start date (Y-M-D):
End date (Y-M-D):

Position title:
Excluded position number:
Start date (Y-M-D):
End date (Y-M-D):

Position title:
Excluded position number:
Start date (Y-M-D):
End date (Y-M-D):

LEAVE OF ABSENCE / ASSIGNMENT

List below all periods of leave of absence with or without pay (aside from vacation periods) or assignments in which you were not actively employed at the OGGS (e.g. educational leave, personal leave, or sick leave).

NOTE: Any period of leave of absence without pay (excluding maternity leave, parental leave, or sick leave) or assignment will not be included in the calculation of the three-year qualifying period, but it does not constitute a break in the employment relationship. Any break in the employment relationship will result in the time count restarting.

Reasons:
Start date (Y-M-D):
End date (Y-M-D):

Reasons:
Start date (Y-M-D):
End date (Y-M-D):

Reasons:
Start date (Y-M-D):
End date (Y-M-D):

DOCUMENTS REQUIRED

Please attach the following documents to this form:

1. A letter from the person responsible for the pay administration at the OGGS confirming:
   • the start and end date of the continuous service in one or more of the following excluded positions GGS-S-910 to GGS-S-920;
   • any periods of leave of absence with or without pay, or assignment; and
   • confirmation of the last day remunerated as person employed in an excluded position.
2. A photocopy of the pay card maintained by the pay office which substantiate the period(s) of employment.

ADDITIONAL INFORMATION

Describe any exceptions or concerns related to the statements listed above or any other information that might help the PSC determine your eligibility to participate in an advertised internal appointment process for which the organizational criterion established under section 34 of the PSEA, entitles all employees to be considered.

SIGNATURE

The undersigned confirms that the information provided herein and/or attached is accurate and complete, and that they:

• were employed by the Office of the Governor General's Secretary; and
• in one of the specified excluded positions.
  

Name (please print):
Position title:
Signature:
Date:

PSC CONTACT

Should you require additional information, please contact the PSC's Political Activities and Non-Partisanship Directorate at 1-866-707-7152, or by email at pa-ap@psc-cfp.gc.ca.

THIS APPLICATION CAN BE MAILED OR FAXED TO:

Director General
Political Activities and Non-Partisanship Directorate
Policy Branch
Public Service Commission of Canada
300 Laurier Ave. West, 12^th Floor
Ottawa, Ontario K1A 0M7
Fax no.: (613) 995-7699