8/2018
Main Office: One Winter Street, 8th Floor, Boston, MA 02108 Phone: 617-367-7770 Fax: 617-723-1438 Toll Free (within MA): 1-800-392-6014
Regional Office: 436 Dwight Street, Room 109A, Springfield , MA 01103 Phone: 413-730-6135 Fax: 413-730-6139
mass.gov/retirement
|
THIS SECTION BOARD USE ONLY
|
SECTION A TO BE COMPLETED BY MEMBER:
Member’s Name: Social Security No.:
Address: Date of Birth:
City/State/Zip:
Contact Tel: Current Employing Agency:
Applying for:
0 Group 2 0 Group 4 0 20/50 (Corrections Ocers Only)
Job Title for Group Classication:
Member Questionnaire:
1. Are you an active member currently employed with the Commonwealth? Yes No
2. Did your membership begin before April 2, 2012?
¾ If you are an active member and you entered service before April 2,
2012 you may elect to pro-rate your service by group classication.
Yes No
3. Are you seeking pro-rated service by group classication?
¾ If yes, you must submit a separate Group Classication Application
for each position you are seeking group classication.
¾ Pro-rated service is mandatory for members entering service
April 2, 2012 or later.
Yes No
4. How many Group Classication Applications are you submitting?
(including this one) _________________________
5. Please report the name of the state agency that employed you for the
group classication you are seeking: _________________________
6. List the approximate dates of employment in the position for which you
are seeking group classication (MM/DD/YY): ___________ TO ___________
Please attach a narrative description of your daily responsibilities for the position you seek group classication;
whether you supervise other employees; and if you work with a specic population of individuals. If your
position has changed within the last twelve months, please describe the circumstances of that change and
your position and job duties immediately prior to that change.
I hereby certify under the penalties of perjury that the above information is true and accurate.
Member Signature Date
Instructions:
A Group Classication Application must be submitted for each position for which a member is seeking Group Classication. The
member must rst complete Section A and submit the application and all attachments to the human resources department at the
agency which employed them in the position for which they seek group classication. The agency must then complete Section B
and submit the application and all attachments to the Board. The complete application must be reviewed by the member’s direct
supervisor or the current supervisor familiar with the duties of the position being reviewed.
APPLICATION FOR
GROUP CLASSIFICATION
