NEW MEMBER ENROLLMENT

(Please Print – Instructions on Reverse)

Social Security Number: __ __ __- __ __ -__ __ __ __ Retirement Date: _____________________________

Name: _______________________________________ Last PEF Division#: __________________________

Address: ________________________________________________ City:____________________________

State: __________________ Zip: __________________ NY County:________________________________

Telephone: (_____)___________________ E-mail Address: ________________________________________

Return your completed enrollment card and signed $18 check to:

PEF Retirees

1168-70 Troy Schenectady Road PO Box 12414

Albany, New York 12212-2414 RET1670-5/07

The Social Security number is required by the Retiree Office for positive identification. The Retiree Office

does not share the Social Security number with any other organizations and does not print the Social Security

number on any records or documents. It only appears on computer screens when a record is displayed.

For Retirement Date, please use your last day on the payroll.

If you remember your old Division number, please write it in. If you do not remember it, write in your last

agency and work location.

Please give us your e-mail address as we plan to develop an electronic newsletter in order to reduce postage

costs. Your e-mail address will NOT be shared with any other organizations.

I N S T R U C T I O N S

Completed forms and $18 signed check should be mailed to:

PEF Retirees  1168-70 Troy-Schenectady Road  P.O. Box 12414  Albany, New York 12212-2414