Form Trs 100 - Teachers' Retirement System Enrollment Member Information Record
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2TRS Enrollment Member Information Record
Teachers’ Retirement System of Alabama
PO Box 302150, Montgomery, Alabama 36130-2150
877.517.0020 • 334.517.7000 •
Your SSN
Check One: q New Member q Transfer from another TRS 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
Employing Agency ____________________________________
Position You Will Hold: 1 q Teacher 3 q Superintendent 5 q Clerical
7 q Maintenance 9 q Mechanic
__________
2 q Principal 4 q Administrative
6 q Lunchroom 8 q Bus Driver
10 q Other
(Specify)
Have you ever been employed by a state agency other than in public education in Alabama?
q Yes q No
Have you ever been a member of the Teachers’ Retirement System of Alabama?
q Yes q No
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Have you ever withdrawn contributions from the Retirement Systems?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 _______________________________________ Employment Date _________________________________
Certification
To be completed by
Annual Contract Salary _________________________________ Number of Days Contracted __________________________
the employing agency
Number of Pay Periods Per Year ____________________________ % of Full Time _____________________________________
Sign Here
Employer Signature ________________________________________________ Date Submitted ___________________
è
Employer
Title _______________________________________________
T
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ox is for
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Comments: _________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
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