Previous State Employment Verification Form
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1Previous State Employment Verification
.
INSTRUCTIONS:
Complete the top section and send one form to each prior Texas state employer for verification
Privacy Notice: State law requires that you be informed that you are entitled to: (1) request to be informed about the information collected about
yourself on this form (with a few exceptions as provided by law); (2) receive and review that information; and (3) have the information corrected at no
charge. To request this information, contact
payroll@tamu.edu
or (979) 845-2711.
Name:
SSN:
(required for proper verification)
The name of the state agency at which I was employed is below:
Name of Agency:
Department:
Name used during employment:
Approximate dates of State employment:
From (date):
To (date):
I understand that my Social Security Number is required in order to complete a Prevous State Employment Verification.
My signature below serves as my consent. Furthermore, I have authorized my prior employer to release all requested
information below to Texas A & M University.
Signature___________________________________ Date___________________________
Form to be returned to my current department at Texas A & M University.
Department ________________________
Fax Number ________________________
------------------------------------------------------------------------------------------------------------------------------------------------
This section to be completed by State Agency or Institution and returned to fax number above.
Name of
Agency
State Agency_____________________________________________Number__________________
Dates of Service from_______________________________ to _____________________________
from_______________________________ to ____________________________
from_______________________________ to ____________________________
Amount of transferable sick leave (if applicable)_________________________hours.
Amount of transferable annual leave (if applicable_______________________ hours.
Benefit Replacement Pay (BRP) eligible?
_____Yes
____No
Annual amount $____________
Information supplied by:
Printed Name__________________________________Signature__________________________________
Title__________________________________________Date______________________________________
Phone________________________________________Email_____________________________________
Questions:
979-845-9505
#358 Previous State Employment
Revised 10/22/2012
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