Form Sp-10-0008-0511 Enrollment Application
ADVERTISEMENT
1
2SP-10-0008-0511
STATE POLICE RETIREMENT SYSTEM
NEW JERSEY DIVISION OF PENSIONS AND BENEFITS
ENROLLMENT APPLICATION
(Read the accompanying instructions carefully before completing this application.)
FOR DIVISION USE ONLY: Location No.: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Membership No.: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
PART I: (Please Print or Type)
1.
Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Last
First (No nicknames)
Middle
Maiden Surname
2.
Address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Street Name
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
City
State
Zip Code
3.
Social Security Number: ______________________________________________________
4.
Sex:
Male
Female
5.
Date of Birth: _____/_____/_____
Mo.
Day
Year
6a. Are you a former member of the retirement system?
Yes
No
6b. Enter any other name(s) used during previous membership(s): _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
7a. Enter the name of any public retirement system in which you are or have been a member in this or any
other state: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
7b. Are you receiving benefits from any retirement system at this time?
Yes
No
PART II: CERTIFICATION OF EMPLOYING AGENCY (
To be completed by your employer.)
1.
Name of Employer: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
2.
Payroll Number:
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
3.
Payroll Title of Applicant: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
4.
Enlistment Date: _____/_____/_____
5. Date employee completed Academy training: _____/_____/_____
Mo.
Day
Year
Mo.
Day
Year
6.
Date medical requirement was approved by the examining physician: ____/____/____
Mo.
Day
Year
7.
Current Annual Base Salary $________________________________
(Salary only - Do not include Maintenance)
8.
I certify that this employee and position meets the eligibility criteria for the retirement system as provided by law.
I acknowledge that I am subject to penalty for falsifying or permitting to be falsified any record, application, form, or
report of the retirement system in an attempt to defraud the system pursuant to N.J.S.A. 43:3C-15. (Two Signatures
Required)
_______________________________________________
__________________ __________________________
Signature of Certifying Officer
Title
Date
_______________________________________________
__________________ __________________________
Signature of Certifying Officer’s Supervisor
Title
Date
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Parent category: Financial