PERS Questionnaire
Name:
Please answer each of the following questions pertaining to previous or
current public employment:
1. Have you ever been employed in California by the state, a county, or city?
Yes No
2. Are you currently employed (in addition to this position) in California by the state,
county, or city? Yes No
3. Have you ever been employed in California by a school/college district previous to
this appointment? Yes No
4. Are you currently employed (in addition to this position) in California by a
school/college district? Yes No
5. Are you or have you been a member of the “Public Employees Retirement System?”
(PERS) Yes No Not Sure
6. If yes, have you withdrawn contributions? Yes No Not Sure
7. Have you redeposited contributions? Yes No Not Sure
8. Are you retired and receiving a monthly allowance from PERS? Yes No
Please read the statement below and sign the bottom of the form
*I understand that my appointment at Cuesta College may be subject to membership in
the Public Employees Retirement System (PERS). I agree to inform the Human
Resources Office at Cuesta College if I become employed at another agency while
working at Cuesta College, where I am enrolled in the Public Employees Retirement
System (PERS).
Signature___________________________________ Date _________________
