Member Enrollment Form (Choice Agency) - Public Employees' Retirement System Of Nevada
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1
2Public Employees’ Retirement System of Nevada
693 W. Nye Lane, Carson City, NV 89703 (775) 687-4200 Fax (775) 687-5131
5740 S. Eastern Ave. Suite 120, Las Vegas, NV 89119 (702) 486-3900 Fax (702) 678-6934
Toll Free 1-866-473-7768 Website:
Email:
MEMBER ENROLLMENT
(Choice Agency)
This form should be completed for all new hires that are eligible for enrollment under NRS 286.293. This form is also used to enroll persons who have returned from
leave without pay or from ineligible status, or for a retired employee electing to re-enroll under authority of the Critical Need Provision.
Member Information (Please print legibly, using black or blue ink)
SS#___________/____________/___________
Name:
Date of Birth:
__________________________________________________________________________
__________/__________/__________
Last – Suffix
First
MI
Mo
Day
Yr
Registered
Address:
Married
Single
_________________________________________________________________________
Domestic
Partner
City:
State:
Zip:
Male
Female
______________________________________
___________
___________________
Personal Email: ___________________________________________________________
Prior Agency / Name Information
List prior Nevada Public Agencies where you have worked:_____________________________________________________________________
List any other names under which you were enrolled in PERS:___________________________________________________________________
Are you currently employed with a second Nevada public employer? ________________
Yes, please list:_____________________________
(Before initialing below, be sure to read the accompanying form entitled “Contribution Plan
Election of Contribution Plan
Descriptions” for a full explanation of the two contribution plans available to you).
Initial One:
________Employee/Employer Plan
________Employer-Pay Plan
Member’s Signature: __________________________________________________
Date:_____________________________________
Agency Information and Certification
(To be completed and signed by agency liaison officer or authorized rep.)
Agency Name:__________________________________________________________Budget #:______________Agency #_________________
3-Digit Number
Member Enrollment Date:____________________________
Member Returned from LWOP / Ineligible Date: _______________________
Position Title:
Full-time
Part-time
_______________________________________________________________
All Agencies Must List Member’s Position Title
Is Member: (Check only one)
Ordinary Member
Police/Fire Member
Volunteer Fire Member
Legislator
Retired Employee – Position Approved Under Critical Need Provision (attach approval document)
Retired Employee – Non Critical Need Position
If Elected Official, check appropriate box:
Commissioner
Councilman
Mayor
Other Elected Official
For School Districts Only:
Position Type How is the Member Paid?
9 months out of 9 (9/9)
9, 10, 11 months out of 12 (9/12)
12 months out of 12 (12/12)
Is Member under contract?
No
Yes, Give Start Date
I certify that this individual is employed in a position requiring half-time or more service according to
employer’s full-time work schedule.
Signature:
Date:
Liaison Officer or Authorized Representative
Print Name:_____________________________________________________
Rev. 1/17
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