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PSRS Members

Part-Time Certificated Employment Request

You will receive a written response by mail at the address you provide below.

*First Name:
Middle Initial:
*Last Name:
*Member Number:
Tip: Look on your annual PSRS Member Statement to find your member number.
*Street Address:
*City, *State, *Zip
, -
*Telephone Number:
 Email Address:
   
*Beginning Date of  Employment:
mmddyyyy
*Ending Date of  Employment:
mmddyyyy
*District Employed By  During Part-Time Service:
*Name During Service:
   
* Required Fields