| Request For Verification
of Service New York City Department of Education Division of Financial Operations Office of Employment Records Research 65 Court Street - Room 1703, Brooklyn, N.Y. 11201 | |||
| Please complete all items for verification of employment with the
N.Y.C Department of Education Only service performed during time periods when employee was not a member of a retirement system can be verified by the Office of Employment Records Research. |
| Date | File Number | |||
| Social Security # | Day Time Phone # | |||
| First Name | Last Name | |||
| Maiden Name | M.I. | Pension Membership Date | ||
| Home Address | Apartment Number |
|||
| City | State |
Zip |
||
| Email |
Employee Signature _________________________________________ |
|||
| Type of
Service (Check all that apply) |
Dates of
Employment From To |
School/Office (Location of Employment) |
District/Boro |
| Regular Teacher | - | ||
| Regular Substitute | - | ||
| Per Diem | - | ||
| Hourly Pro/Per Session | - | ||
| Evening Community Center | - | ||
| After School Playground | - | ||
| Vacation Playground | - | ||
| Youth Board | - | ||
| Hourly School Lunch | - | ||
| Paraprofessional | - | ||
| School Aides, Guards | - | ||
| Administrative | - | ||
| Hourly Administrative | - | ||
| Annual School Lunch | - | ||
| Other (Specify) | - |
|
Forms required by other retirement
systems must be submitted with this request.
Include additional information and unique requests in the comment box below. |
|
| Authorizing Agency:
_______________________ (Name) |
Date:________________________ |