Request For Verification Of Previous Employment Form - University Of California
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Request for Verification of Previous Employment
For University of California, California State University or State of California Employment
Employee’s Request –
To be completed by the employee.
Please Return Form to:
Attention: ______________________________________________
Edna Arellano
Human Resources
Employer: ______________________________________________
SAASB 3101
University of California
Address:
______________________________________________
Santa Barbara, CA 93106-3160
______________________________________________
FAX: 805-893-8645
Email: edna.arellano@hr.ucsb.edu
I am currently working at the University of California, Santa Barbara and need verification of my previous
University of California, California State University or State of California Employment Service. This verification
is required to establish my vacation leave accrual rate at UCSB.* Your prompt response is appreciated!
My signature below serves to authorize the release of the information requested to the University of California,
Santa Barbara.
______________________________________
___________________
______________________________
Employee’s Name (Print)
Date of Birth
Social Security #
______________________________________
___________________
______________________________
Employee’s Signature
Signature Date
Dates of Employment
Employment Service Verification –
To be completed by the University of California or
State of California agency authorized to provide the following employment service verification.
_________________________________
__________________________________
Employment Date
Separation Date
Service Dates (pay status at 50% or more time). Please attach supporting documentation if available.
Status
Total
From
To
Job Title
(staff, academic)
Yrs/Mos
Total Qualifying Service Credit – A month on pay status at 50% time or more is counted as a
month of qualifying service. Service need not be continuous to be counted.
Years
Months
Completed by: (print name & title): _______________________________________________________
Telephone: _______________________________ Email Address: _____________________________
Signature: ________________________________________________
Date: ___________________
* Service credit calculations for vacation leave accrual rates are not the same as calculations for retirement service credit, or used to
determine seniority. Refer to the Benefits office for questions on retirement service credit, and to the Labor Relations office for seniority.
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