Holy Trinity Roman Catholic

Separate School Division

502 Sixth Avenue North East

Moose Jaw, SK S6H 4P8

Application Form

Deferred Salary Leave Plan Form

Name: ____________________________________________

School: _______________________________________________

Current Teaching Assignment: ______________________________

I have reviewed the Deferred Salary Leave Plan for teachers on a permanent contract with Holy Trinity School Division and I would like to apply to participate in the plan.

I would like to participate in the plan as follows:

Deferral Period
Year	From	To
1	_______ ____ Month Year	_______ ____ Month Year
2	_______ ____ Month Year	_______ ____ Month Year
3	_______ ____ Month Year	_______ ____ Month Year
4	_______ ____ Month Year	_______ ____ Month Year

Leave Period
Year	From	To
5	_______ ____ Month Year	_______ ____ Month Year

Date:_____________ Signature:_______________________