PUBLIC EMPLOYEE RETIREMENT ADMINISTRATION COMMISSION
New Member Enrollment 3
Member Last Name:
First Name: SSN: ***-**-__ __ __ __
I hereby authorize the Treasurer to withhold the proper percentage 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 or
other conditions apply. In the event that I die before retiring, my named beneficiary or beneficiaries may receive survivor benefits
OR a refund of my accumulated total deductions as allowed by law.
I sign this application under the penalties of perjury. I affirm that the information presented in this application is correct,
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.
Applicant's Signature:
Print Employee's Name:
Employee's Signature:
Date:
Other Public Employment in Massachusetts
List prior or current public employment in Massachusetts or one of its political subdivisions (Non-membership):
EMPLOYER
DATES OF EMPLOYMENT
From: To:
Veteran Status
Are you a veteran? YES NO
If YES, please enter dates of service and attach a copy of your
military discharge papers, Forms DD-214, DD-215, DD-256,
NGB 22, or NGB 22A.
DATES OF ACTIVE SERVICE
From: To:
