1. No category

NOTICE OF CLAIM
IN THE MATTER OF A CLAIM FOR COMPENSATION
ARISING OUT OF NON-PERMANENT EMPLOYMENT
WITH SASKATCHEWAN POLYTECHNIC
I, ______________________________, of ________________________, in the
Province of ___________________, hereby give notice of my claim for compensation
arising out of my employment with Saskatchewan Polytechnic (the Employer), as a nonpermanent employee during which I was not a member of the Public Employees’
Pension Plan, in accordance with the Non-Permanent Pension Claims Program, the
terms and conditions of which have been provided to me by Saskatchewan Polytechnic.
AND FURTHER TAKE NOTICE that the period or periods of employment after
May 19, 1981 with respect to which I make my claim was as follows:
Location:
Period of Employment:
I ACKNOWLEDGE that by making this claim I am waiving and releasing Saskatchewan
Polytechnic from any legal claim that I may have with respect to the period of
employment that is the subject matter of this claim, and have executed the attached
Release of Claim for that purpose;
AND I FURTHER ACKNOWLEDGE that I must, within 120 days of making this claim,
provide proof of my claim in the form of the Affidavit of Claimant; and
MY FULL MAILING ADDRESS is as follows:
_____________________________________________________________________
IN WITNESS WHEREOF I have set my hand hereto this ____ day of
_______________, 201_ .
SIGNED IN THE PRESENCE OF:
WITNESS SIGNATURE
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CLAIMANT’S SIGNATURE