Office of the New York State Comptroller
Police and Fire Membership Application
New York State and Local Retirement System
110 State Street, Albany, New York 12244-0001
Instructions: Please print clearly in ink or type.
Employee: Complete items 1–3, 12–14 on page 2 and other applicable sections. This form no longer requires a signature for
membership purposes. Employer: Complete items 4–11a.
FOR A REGISTRATION NUMBER: Call 1-866-805-0990 or (518) 474-3081. Or fax the application to (518) 486-4382.
IMPORTANT INFORMATION: Has this person been registered to membership by means of the telephone or
fax registration system?
(If yes, enter the information given to you in the boxes below.)
Street, Apt. or Unit #, PO Box #
Zip Code + 4
Maiden or Other Name Used
Social Security Number*
Date of Birth
* In accordance with the Federal Privacy Act of 1974, you are hereby advised that disclosure of your Social Security account number is mandatory pursuant to Sections 311 and
334 of the Retirement and Social Security Law. Your number will be used in identifying your retirement records and in the administration of the Retirement System.
(Indicate State, or, if not, name of public entity by which employed and Department, Division or Institution) Employer Telephone Number
Employer’s Address (Include Street, City, County, State, Zip Code)
Employer Fax Number
Present Payroll Title:
Check if either applies:
Enter the Information Relating to Employee’s Present Position:
Employment Status – Check each box that applies to this Employee’s position:
Date of First Employmen
Labor Contract Information
Is this member covered by an (existing) unexpired collective bargaining agreement that was in effect on January 9, 2010,
and was still in effect on the date of membership that requires you to offer a Special Plan Election?
If yes, please provide: Effective Date of Contract #_______________________
Termination Date of Contract #_______________________
Member’s Negotiating Unit/Labor Organization _________________________________________________________________
Contributory Status (you must check one):
Frequency of Payment:
Basis of Compensation and Rate (Tier 1, 2, 3 and 5 ONLY):
Daily $_______________ Hourly $_______________
Units of Work Performed $_____________ per _____________________
(Example: $50 per meeting or $10 per examination, etc.)
Basis of Compensation and Rate (Tier 6 ONLY):
Tier 6 requires employers to determine the Annual Wage for individuals who work Part Time,
Seasonal or on an Hourly, Daily or Unit of Work Basis. See the Chart on Page Two for instructions.
Annual Wage $_________________________________