Vendor Information Pickerington Page 3
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4INDEPENDENT CONTRACTOR
ACKNOWLEDGMENT
Ohio Public Employees Retirement System
Employer Outreach: 1-888-400-0965
277 East Town Street, Columbus, Ohio 43215-4642
This form is to be completed if you are an individual who begins providing personal services to a public employer on or after
Jan. 7, 2013 but are not considered by the public employer to be a public employee and will not have contributions made
to OPERS. This form must be completed not later than 30 days after you begin providing personal services to the public
employer.
STEP 1: Personal Information
Social Security Number
First Name
MI
Last Name
STEP 2: Public Employment Information
Name of Public Employer
Employer Contact
First Name
MI
Last Name
Employer Code
Employer Contact Phone Number
Service Provided to Public Employer
Start Date of Service
End Date of Service
Month
Day
Year
Month
Day
Year
PEDACKN (Revised 12/2012)
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