Multiple Employment Membership Status Employment History Data

MULTIPLE EMPLOYMENT MEMBERSHIP STATUS
EMPLOYMENT HISTORY DATA FORM
(NOTE: Please print in black or blue ink, and initial any changes that you make on this form.)
PART A: All information must be provided.
First Name
MI Last Name Permanent Home Address
Social Security Number (last 4 digits only)
XX X X X
Apt. No. TRS Membership Number
City State Zip Code
Primary Phone Number (Check one:
(
)
Alternate Phone Number (Check one:
(
)
Home
Home
Work
Work
Mobile)
Mobile)
Please keep your personal information with TRS up to date. We will update our records based on the information you provide above,
so do not enter a temporary address; instead, TRS suggests that you consult the U.S. Postal Service about having your mail forwarded
on a temporary basis. To register any changes to your permanent address (and/or phone number), please access our website or file a
“Member’s Change of Address Form” (code DM13) with TRS.
If you are providing new information above, please indicate the effective date:
To be considered for Multiple Employment Membership status, you must provide the information requested in Part B and
send this form to your former employer. Please advise your former employer to complete Parts C and D, and send the
completed form to TRS at the above address.
PART B: TO BE COMPLETED BY THE MEMBER. Please complete the following and sign below.
I,
, was formerly employed with
.
I request that this employer provide TRS with my employment history for the period(s) of
MEMBER’S SIGNATURE
RW67 (4/10) .
DATE (M/D/Y)
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PART C: TO BE COMPLETED BY A PERSONNEL REPRESENTATIVE OF THE FORMER EMPLOYER, WHO
SHOULD MAIL THISCOMPLETED FORM TO TRS AT THE ADDRESS ABOVE. The representative must complete
both sections of Part C.
SECTION 1: In the table below, please indicate the school name, the period(s) during which the above-mentioned
member rendered employment (including any breaks in service with or without pay), the payroll title(s)
held, the salary rate(s) paid, and the total service rendered (hours, days, sessions, etc.) for the abovementioned member.
(NOTE: Please list the member’s most recent position first. If needed, you may attach an additional sheet of paper.)
SCHOOL NAME
PERIOD OF EMPLOYMENT
EMPLOYMENT STATUS*
PAYROLL TITLE
SALARY
SERVICE RENDERED
* (e.g., full-time; part-time; evening session; summer session; sabbatical; paid leave; substitute per-diem; other)
SECTION 2: Please provide all applicable information below.
To the best of your knowledge, did this member participate in the TIAA-CREF pension plan? Yes No
Unsure
If this member was granted leave without pay, during which period(s) did the leave(s) occur, and why did the member take
the leave(s)?
If the above employee is/was a CUNY employee:
• To the best of your knowledge, which colleges other than those listed on the front of this form (if any) have employed
this member?
• To the best of your knowledge, during what time periods not indicated on the front of this form (if any) has this member been
employed by CUNY?
RW67 (4/10) CONTINUED ON PAGE 3
PAGE 2
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• To the best of your knowledge, what was the nature of this member’s work while employed by CUNY?
PART D: TO BE COMPLETED BY A PERSONNEL REPRESENTATIVE OF THE FORMER EMPLOYER.
Personnel Representative’s First Name
MI Last Name Official Title
PERSONNEL REPRESENTATIVE’S SIGNATURE RW67 (4/10) Business Telephone Number
(
)
DATE (M/D/Y)
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