NPERS6300 Rev. 09/2013 Page 1 of 1
BAR CODE
Employer Name
Date
Plan Type
(Check One)
Agency/County Number / District Number
School
State
County
Judges
Patrol
Address
City State Zip
PRIMARY CONTACT INFORMATION
CONTACT NAME TITLE
ADDRESS
TELEPHONE NUMBER FAX NUMBER EMAIL ADDRESS
SIGNATURE DATE
ADDITIONAL CONTACT INFORMATION
CONTACT NAME TITLE
ADDRESS
TELEPHONE NUMBER FAX NUMBER EMAIL ADDRESS
SIGNATURE DATE
CONTACT NAME TITLE
ADDRESS
TELEPHONE NUMBER FAX NUMBER EMAIL ADDRESS
SIGNATURE DATE
Employer Contact
Please complete this form to include the name(s) of the people the Nebraska Public Employees Retirement Systems (NPERS) may record as point
of contact. Your Primary Employer Contact should be an individual who is familiar with your employment policies, your payroll system, and the
retirement plan and who has access to your personnel records. You may choose whom you wish to be your Primary Employer Contact and may also
choose other Additional Contacts. All general correspondence from NPERS will be addressed to the Primary Contact.
If the individual who is the Primary Contact or anyone listed as an Additional Contact should change, please complete and submit a new form.
