Certificated Personnel Information Form Print On Blue Paper

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CERTIFICATED PERSONNEL INFORMATION FORM
Monterey County Office of Education
Certificated Employee to Complete
<select>
Social Security Number ______/_____/______ Date of Birth ______/_____/______ Gender ____________
Last Name __________________________
First Name ______________________ M.I. ___________
Former Name (if applicable) _______________________________________________________________
Address _______________________________________
City _________________________________
State ___________ Zip _________________________
Phone Number ( _____) _______ - _______
Is this your first public teaching experience in California?
<select>
If no, year and County you last taught: Year ________ County __________________________________
Have you previously taught in Monterey County?
If yes, Year _________________________
<select>
Are you presently teaching in another school district?
<select>
If yes, District Name ______________________________
Status:
<select>
Are you retired?
If yes, name of district _____________________________________________
<select>
If you are not teaching, where are you presently employed? ______________________________________
Are you a member of the State Teachers’ Retirement System?
<select>
If no, did you
Date _________________________
<select>
If a non-member, was the Permissive Election and Acknowledgement Form MR350 provided and explained to
you?
<select>
Employee Signature ____________________________________ Date __________________________
School District to Complete
District Name ___________________________________
First Date Worked in Position ______________
<select>
0.00%
Pay Frequency:
% Contract __________
Non Full-time Status:
<select>
District REAP Verification:
__________________________________________________
<select>
District Signature _______________________________________ Date __________________________
IMPORTANT DISTRIBUTION INSTRUCTIONS:
• Contracts and Election into Membership: Submit “blue” form with Election form to MCOE immediately.
• Substitutes who Do Not Elect: Submit “blue” form to MCOE the month substitute is first paid.
MCOE to Complete
<select>
<select>
REAP Member Status _______________
Date ________________
Reap Status __________________
MCOE STRS History _____________________________________________________________________
PRINT ON BLUE PAPER

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