Public Employees’ Retirement System of Mississippi
429 Mississippi Street, Jackson, MS 39201-1005 800.444.7377 601.359.3589 601.359.5262, fax
Membership Application
Form 1 Revised 07/01/2016
Please print or type in black ink. Completed form should be mailed or faxed to PERS. See bottom of form for contact information.
Member Information Attach a copy of the member’s Social Security card.
First Name: _______________________________________ MI: ______ Last Name: ______________________________________ Gender: M F
Provide previous name, if applicable. First Name: _______________________________ MI: _____ Last Name: __________________________________
Social Security No.: ______________________ Birth Date mm/dd/ccyy: ____________________ E-Mail: ________________________________________
Mailing Address: _____________________________________________________________ City: ______________________ State: _____ Zip: ________
Phone: _______________________________ Cellular Home Work Phone: _______________________________ Cellular Home Work
Have you previously served on active duty in the U.S. Armed Forces? If yes, attach Form(s) DD214 ........................................................... Yes No
Have you ever been a member of the Optional Retirement Plan (ORP) for Institutions of Higher Learning in the State of Mississippi? ................. Yes No
Retirement Plan Plans are governmental defined benefit plans qualified under Section 401(a) of the Internal Revenue Code. Select applicable plan.
Public Employees’ Retirement System of Mississippi (PERS) Mississippi Highway Safety Patrol Retirement System (MHSPRS)
Supplemental Legislative Retirement Plan (SLRP)
Family Information Use additional Membership Applications if listing more than four dependent children. Information is for determining statutory
benefits only. Use Form 1B, Beneficiary Designation, to officially designate any and all beneficiaries.
Marital Status Select one. Add date for last three. Single Married Divorced Widowed Effective Date mm/dd/ccyy: ________________
Spouse’s Full Name Social Security No. Birth Date mm/dd/ccyy Wedding Date mm/dd/ccyy Gender
_____________________________________ ____________________________ _______________________ _______________________ M F
Dependent Child’s Full Name Up to age Social Security No. Birth Date mm/dd/ccyy Relationship Gender
19, or 23 if unmarried and a full-time student
_____________________________________ ____________________________ _______________________ _______________________ M F
_____________________________________ ____________________________ _______________________ _______________________ M F
_____________________________________ ____________________________ _______________________ _______________________ M F
_____________________________________ ____________________________ _______________________ _______________________ M F
Member Certification If an authorized representative signs this form, attach a copy of the durable power of attorney, conservatorship or
guardianship papers, or other legal documents as proof of authority to sign this form.
Member’s Signature: ______________________________________________________________________ Date mm/dd/ccyy:______________________
Employer Certification This section must be completed by an authorized employer representative, not the member.
Member’s Position Held/Job Title: _____________________________________________ Member’s Hire Date mm/dd/ccyy: _____________________
Member’s Status: Elected Official: Yes No Fee Paid Official: Yes No Public Safety Employee: Yes No
Employer Name: ____________________________________________________________ Employer No.: __________________ - _________________
Employer Representative’s Name: ________________________________ Employer Representative’s Title: _____________________________________
Employer Representative’s Phone: _________________________ Fax: __________________________ E-Mail: __________________________________
As employer representative, I certify that employment in this position meets the eligibility requirements of PERS Board of Trustees Regulation 25, Eligibility of
Part-time Employees for State Retirement Annuity Service Credit, and PERS Board of Trustees Regulation 36, Eligibility for Membership in the Public
Employees’ Retirement System of Mississippi (PERS).
Employer Representative’s Signature: _________________________________________________________ Date mm/dd/ccyy: _____________________
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