Rev. 7/14/20 CUNY Employment Application Part 3 1
THE CITY UNIVERSITY OF NEW YORK EMPLOYMENT APPLICATION – PART THREE
CERTIFICATION OF NEW YORK STATE OR NEW YORK CITY PUBLIC SERVICE
CERTIFICATION OF COLLECTION OF PUBLIC PENSION FUNDS
Under the New York State Retirement and Social Security Law, retirees collecting a pension from New York State
or New York City cannot (with certain exceptions) work at the University and continue to collect their pension.
Accordingly, The City University of New York requires individuals seeking University employment to disclose
their public employment and pension plan history for the purpose of establishing eligibility for employment. An
employee who fails to disclose such information will be subject to appropriate action, which may include
disciplinary action to terminate their employment and/or suspension or diminution of the retiree's public
pension benefits.
No
te: Retirees who are under age 65 and are collecting a pension may receive an annual income of up to $30,000
(Thirty thousand only) in a position in public employment without diminution of their pension benefits.
1. Candidates for employment must submit this form at the time of hire, prior to any appointment
2. All full-time and part-time employees are responsible for submitting this form, should their status
change
3. Adjuncts who are retirees must submit this form every semester in which their employment continues
L
ast Name: __________________________ First Name: ___________________________ Middle Initial: ________
C
ollege: ______________________________________ Department: ________________________
________
C
ontract Title: _________________________________ Full Time Part Time
C
urrent Positions in Public Service (please check appropriate box)
I
am not currently working for another public service agency, organization or jurisdiction funded by New
York City or New York State, not have I worked at any such entity during the calendar year.
I
am now working for another public service agency, organization or jurisdiction funded by New York City
or New York State.
Name of Employer: _______________________________________________________
I am a statewide elected official of New York State.
I am a New York State Legislative employee.
I
am a member of the New York State Legislature.
I
am a New York State officer or employee (other than CUNY employee) and I receive compensation other
than on a per diem basis.
