Form Com 4751 - Form Srsio State Retirement System Investment Officer - Ohio Dept.of Commerce Page 3
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3To avoid delays in processing, furnish correct names and addresses of all employers. State if
former employer is out of business. For additional space please attach a separate sheet.
Period of Employment
Employer's Names & Address
Nature of Employment
From:
Name
To:
Address
From:
Name
To:
Address
From:
Name
To:
Address
From:
Name
To:
Address
PART V: Signatures
1. Applicant
The undersigned represents that the foregoing information is true and accurate to the best of
the applicant’s knowledge as of the date hereof, and agrees that this form constitutes a
written statement for purposes of R.C. 1707.44(B).
________________________________________
Applicant’s signature named in Part II
________________________________________
Date
2. Retirement System
The undersigned represents that he/she is duly authorized to do so, the foregoing applicant is
employed or has been offered employment, and represents that the information provided in
foregoing Parts I, II and III is true and accurate to the best of the retirement system’s
knowledge as of the date hereof, and agrees that this form constitutes a written statement for
purposes of R.C. 1707.44(B).
_____________________________________
State Retirement System named in Part I
By: __________________________________
Signature (Cannot be the same person as Applicant named in Part II)
Print name and title
Date
EOE/ADA SERVICE PROVIDER
FOR TTY USERS DIAL ORS 1-800-750-0750
COM 4751 (5/05)
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