Form Ers 100 - Ers Enrollment Member Information Record
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1
2ERS Enrollment Member Information Record
Employees’ Retirement System of Alabama
PO Box 302150, Montgomery, Alabama 36130-2150
877.517.0020 • 334.517.7000 •
*ERS 100//1/*
Your SSN
Check One: q New Member q Transfer from another ERS Agency
Your
Name __________________________________________________________________________________________
Information
First
Middle/Maiden
Last
No initials please
Address _________________________________________________________________________________________
Street or P.O. Box
City
State
ZIP Code
Daytime Telephone ___________________________ Email Address _________________________________________
(
)
Date of Birth ________________________________ Sex
q Male q Female
Status
q Married q Single q Widowed q Divorced
Employer
Employing Agency ____________________________________ Section or Division _________________________________
Information
Classification or title of position or elected office you hold _____________________________________________________
Daytime Telephone ___________________________ Email Address _________________________________________
(
)
q Yes q No
Are you an Elected Official?
q Yes q No
Have you ever been employed by any agency of public education in Alabama?
q Yes q No
Have you ever been a member of the Employees’ Retirement System of Alabama?
Were you a member before beginning employment with your current employer?
q Yes q No
Have you ever withdrawn contributions from the Retirement Systems?
q Yes q No
If you answered yes to any of the preceding four questions, please provide the information requested below, listing most recent
employment first.
Employing Agency
City
Year
Under What Name
Date Terminated
Sign Here
Your Signature ______________________________________________________ Date ___________________
è
Employer
Employing Agency _________________________________________________________________________________
Certification
To be completed by
Annual Salary _____________________________________________________ Employment Date ___________________
the employing agency
Number of Pay Periods Per Year ________________ Employment Status (full-time, 1/2 time, 3/4 time, etc.) ___________________
Sign Here
Employer Signature ________________________________________________ Date Submitted ___________________
è
Employer
Title _______________________________________________
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Comments: _________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
continued on next page
ERS 100
REV 4-16
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