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New Jersey State Civil Service Commission

- Intergovernmental Services Unit

Division of Classification and Personnel Management

P.O. Box 313, Trenton, New Jersey 08625-0313

INTERGOVERNMENTAL TRANSFER AGREEMENT

All rules, regulations, policies and procedures effective at the date on which this agreement is signed apply.

Intergovernmental transfers are subject to approval by the Civil Service Commission prior to the effective date of the transfer.

This document is a consensual, voluntary transfer agreement by the sending jurisdiction, the receiving jurisdiction, and the employee and

contains the conditions by which:

______________________________________, _______________________________________________, _____________________

Transferee Name

Present Permanent Title

Current Salary

Requests a transfer from: ______________________________________________________________ _______________________

Sending Jurisdiction

Jurisdiction Code

To: _______________________________________________________________________________ _______________________

Receiving Jurisdiction

Jurisdiction Code

EMPLOYEE AGREEMENT

______________________________________ __________ ______ __________

____/____/____

Signature of Employee

Social Security Number

Date

Pension system of which you are an active member:

PERS

PFRS

OTHER

Date of Birth: ____/___/_______

A Waiver of all accumulated seniority and/or sick leave shall be afforded to those in Law Enforcement titles. Please see the attached waiver.

Providing your social security number is voluntary. It will be used only to keep records for this program,

which is established by N.J.A.C. 4A:4-7.1A.

SENDING JURISICTION AGREEMENT

(TO BE COMPLETED ONLY BY THE APPOINTING AUTHORITY)

Transferees shall retain accumulated seniority rights and sick leave, except for those transferring in the title of Firefighter or those in Law

Enforcement titles who have signed the attached waiver. Vacation leave balances will not be carried forward by the transferee. The transferee

will be paid, on a pro-rated basis, for vacation time earned prior to the effective date of transfer.

CONTACT INFORMATION (Please Print):

_______________________________________________________________________________________________________

ADDRESS

__________________________________________________________________________ (______) _____________________

CITY / STATE / ZIP

TELEPHONE

__________________________________________________________________________ (______) _____________________

EMAIL ADDRESS

FAX

As the Sending Jurisdiction’s authorized signing authority, I by approving and signing below, hereby certify to the receiving

jurisdiction and the Civil Service Commission that no supplemental compensation for accumulated sick leave has or will be paid to

the transferee.

This transfer has been

Approved

Requested Termination Date: _______________________________________

Appointing Authority (Authorized Name and Signature of Authority as listed with CSC):

____________________________________________________, __________________________________________

Authorized AA Name

Title

_____________________________________________________________________

______________________

Signature of Approval

Date

DPF-721 Revised 5/30/12

Page 1 of 2

Form Dpf-721 - Intergovernmental Transfer Agreement - New Jersey State Civil Service Commission

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