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2. 
4. Provisional, Full-time, or Part-time Employee Information Sheet
6. EMPLOYEE COMPLETES:
8. NAME*
9. Social Security #*
11. Date of Birth*
12. Sex*

    1. M
    2. F
13. Telephone Number*
15. *If under 18 years old, are working papers on file?

    1. Yes
    2. No
17. Address*
19. In Case of Emergency Contact*
20. Telephone Number*
21. Relationship*
23. NYS Retirement Registration #
24. Tier
26. Retirement Plan Declined (Signature Required)
28. Health Insurance Plan
29. Option
31. Health Insurance Plan Declined (Signature Required)
33. If declined, is employee eligible for a buyout?

    1. Yes
    2. No
35. FOR PERSONNEL USE:
37. Employee's Title
39. Date of Provisional Appointment
40. Date of Permanent Appointment
41. Date of Civil Service Appointment
43. SALARY/HOURLY RATE
44. DEPARTMENT
46. Employment Eligibility Verification on File

    1. YES
47. Affidavit of Optional Retirement Membership on File

    1. YES
49. Date of Termination
50. Resignation on File

    1. YES
52. Entered
53. By
55. Verified
56. By
58. 3/99
60. Revised 2/08
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61. Print Only

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