Form 2001 - Membership Information - Kentucky Retirement Systems
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1Kentucky Retirement Systems
Perimeter Park West
1260 Louisville Rd.
Frankfort KY 40601-6124
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Phone: (502) 696-8800
Fax: (502) 696-8822
kyret.ky.gov
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Form 2001
Print Form
Revised 07/2015
Membership Information
Member Information
Please provide your Member ID or Social Security number in the Member ID box below.
Member Name:
Member ID:
Address:
City:
State:
Zip Code:
Date of Birth:
Home Phone:
Work Phone:
Email address:
Marital Status:
Sex:
Male
Female
Full Name of Employing Agency:
Other Name Under Which You May
Date of Employment with Agency:
Have Been Previously Employed:
Previous County, City or State Employment
Department or
From
To
Administrative Use
Agency
Position
Month Day Year
Month Day Year
Month Day Year
Statement of Active Duty Military Service
Certification
I understand that no benefits may be paid to me or my beneficiary until this completed form is filed at the retirement office.
Signature:
Date:
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