Form Ee 0681 0710 – Fill Out and Use This PDF

EE-0681-0710

ENROLLMENT APPLICATION INSTRUCTIONS

(This application to be completed by enrolling employer)

APPLICANT INFORMATION

1.Name — Enter applicant's full name (last, first, and middle initial; no nicknames). If applicant has a previous membership under a maiden or other name, enter that name in the space provided.

2.Address — Enter applicant's current mailing address.

3.Social Security Number — Enter applicant’s Social Security number.

4.Gender — Indicate applicant's gender.

5.Date of Birth — Enter applicant's date of birth. Proof of age is required at the time of retirement - if available, attach a photocopy of the applicant's proof of age to this application. Do not delay submitting the Enrollment Application if proof of age is not available. (Acceptable proof of age documents include: birth certificate; passport; naturalization or immigration papers; or certain other records, including baptismal records, military records, census records, school or business records, age recorded on marriage licenses, and insurance or children's birth records.)

6.Daytime Phone Number — Enter applicant's daytime phone number and extension (be sure to include the area code).

7.Is the applicant receiving retirement benefits — Indicate if the applicant is receiving a benefit from a New Jersey State-administered retirement system or local New Jersey retirement system, and give the system's name.

EMPLOYER INFORMATION

8.Employer Name — Enter the full employer name.

9.County — Enter county in which the employer resides.

10.Location, Bureau, and Payroll Numbers — Enter the appropriate location, bureau or payroll number, as applicable. This information should be as reported on your quarterly Report of Contributions (ROC).

11.Title/Position of Applicant — Enter title/position of applicant.

12.Multiple Public Employers — Indicate whether this applicant is employed by more than one public employer. If you answer "Yes", please indicate the full name of each employer.

TPAF APPLICANTS ONLY

13.(a.) Date Employment Began — Enter the date on which applicant started employment. Do not include temporary or substitute service.

(b.) New Jersey Certificate Required — Indicate whether the title/position requires a New Jersey State Certificate issued by the State Board of Examiners within the NJ Department of Education.

(c.) Applicant has New Jersey Certificate — Indicate whether the applicant holds a New Jersey Certificate issued by the State Board of Examiners within the NJ Department of Education.

(d.) Unclassified Professional — For positions with the NJ Department of Education, indicate if the position is "Unclassified Professional".

PERS APPLICANTS ONLY

14. (a.) Date Employment Began — Enter the date on which applicant started employment.

(b.) Permanent Appointment Date — Enter the date of the applicant's regular or permanent appointment.

(c.) Temporary or Provisional — Indicate if the applicant is still considered a temporary or provisional employee.

15.Elected Official – indicate whether the applicant is an elected official. On or after July 1, 2007, a newly elected official is ineligible for enrollment in the PERS. (See Fact Sheet #80.)

16.Appointed Official – Indicate whether the applicant is appointed. State appointees are individuals appointed by the Governor, including those requir- ing the advice and consent of the Senate. Local appointees are individuals appointed by the Governor, including those requiring the advice and con- sent of the Senate or individuals appointed in a similar manner by the governing body of a local entity (county, municipality, etc.). On or after 7/1/07, a newly appointed official who does not have an existing PERS account is ineligible for enrollment in the PERS. (See Fact Sheet #80.)

17.Professional Services Contract – Indicate whether the individual is working under a professional services contract or providing professional serv- ices without benefit of a contract.

18.Base Salary — Enter the annual base salary for the year, that is, the annual salary paid to the employee on the date the Enrollment Application is certified by the employer. Base salary is the contractual salary of the employee. Base salary should not include bonuses, overtime pay, stipends or longevity pay, or sick or vacation time paid in lump sum. Hourly or per diem rates should not be entered.

19.10-12 Month Position — Please indicate whether the position is a 10-month or 12-month position.

20.Hours Worked – Indicate whether the applicant works the requisite number of hours. To be eligible for TPAF or PERS membership, the hours worked by an employee enrolled after May 21, 2010, must be fixed at 35 hours or more per week for State employees to be enrolled in the PERS; 32 hours or more per week for Local Government employees to be enrolled in the PERS; or 32 hours or more per week for State or Local Education employ- ees to be enrolled in the TPAF.

EMPLOYER CERTIFICATION

21.Name of Person Completing Application — Print the name of the human resources representative who completes this Enrollment Application for the applicant.

22.Phone Number — Enter employer telephone number for the person who completed this application (be sure to include the area code and exten- sion).

23.Certifying Officer — The Certifying Officer should print his/her name, then sign and date this application. Unsigned applications will be returned.

Please Note: The newly enrolled member’s estate will automatically be designated as the beneficiary for any death benefit payable. New members should register with the Member Benefits Online System (MBOS) to update their beneficiary information online — or submit a paper Designation of Beneficiary form.