NEW MEMBER ENROLLMENT

(please print-instructions at bottom)

Social Security No.  ____________________________       Retirement Date: __________________________

Name: __________________________________________________   Last PEF Division#: ______________

Address: ___________________________________________   City: ________________________________

State: ____________________    Zip: ___________   NY County: _________________________

Phone: (_____) __________________     E-mail: _______________________________

Return your completed enrollment card to:

PEF Retirees

1168-70 Troy-Schenectady Road  ●  P.O. Box 12414  ●  Albany, New York  12212-2414

Instructions

The Social Security number is required by the Retiree Office for positive identification. The Retiree Office does not share the Social Security number with any other organizations and does not print the Social Security number on any records or documents. It only appears on Computer screens when a record is displayed.

For Retirement Date, please use your last day on the payroll.

If you remember your old Division number, please write it in. If you do not remember it, write in your last agency and work location.

Please give us your e-mail address as we plan to develop an electronic newsletter in order to reduce postage costs. Your e-mail address will NOT be shared with any other organizations.

Completed forms should be mailed to:

PEF Retirees

1168-70 Troy-Schenectady Road  ●  P.O. Box 12414  ●  Albany, New York  12212-2414