List prior or current employment with the Commonwealth or one of its political subdivisions
EMPLOYER DATES OF EMPLOYMENT
Are you a Veteran?
Yes No Dates of Active Duty Service
* The retirement board may request a copy of birth records, miltary discharge papers and other
I hereby authorize the Treasurer to withhold the proper percent of my regular compensation due on each pay
period and to deposit such deductions to my credit in the annuity savings fund. I understand the full amount of
such deductions, with regular interest as provided by law, will be returned to me upon my written request if
I terminate my service, unless I plan to accept a position which would entitle me to become a member of any
other contributory retirement system in the Commonwealth. In the event that I die before retiring, my beneficiary
or beneficiaries may receive survivor benefits or a refund of my accumulated total deductions as allowed by law.
I sign this form under the pains and penalties of perjury. I affirm that the information presented in this form is cor-
rect, complete and accurately presented. I understand that giving false or incomplete information may subject me
to the loss of my benefits as well as civil and criminal penalties.
Employee’s Signature ________________________________________ Date: ___________
To Be Completed by Payroll/Personnel Department and Verified by Retirement Board:
Check base rate to be deducted for retirement:
5% 7% 8% 9% Additional 2%
If 5% or 7% or 8%, state reason:
Current Rate of Regular Compensation per Pay Period:
Employment Status (Check all that apply):
Permanent Temporary Full-time Part-time: 50% 75% Other _____
Authorized Signature: ________________________________________ Date: ___________
To Be Completed by the Retirement Board:
Membership Date $ Annual Regular Compensation % to be deducted
The member must also complete the
Beneficiary Selection Form.
New Member Enrollment Form 2
Member’s Last Name First M.I. Social Security #