Name of employer
    Agency number
    Name of school
    Title of position
    Teachers’ Retirement System of Louisiana
    8401 United Plaza Blvd, Ste 300 • Baton Rouge, LA 70809-7017
    PO Box 94123 • Baton Rouge, LA 70804-9123
    Telephone: (225) 925-6446 • Fax: (225) 925-4779
    www.trsl.org
    Enrollment Application/Employment Notification
    Form 2 (02/05)
    Print in ink or type all entries except signatures.
    This form is designed for multipurpose use and for automated data entry by the Teachers’
    Retirement System of Louisiana (TRSL).
    Name: Last, first, MI, suffix (Jr., III, etc.)
    Street / P.O. Box
    City, state, zip
    Daytime telephone
    Evening telephone
    Check one:
    Citizenship:
    Social Security number
    Section 1 — To be completed by applicant
    Section 2 — To be completed by employer
    Attach copy of card
    Single
    Married
    Divorced
    Legally separated
    Widowed
    ( ) ( )
    Sex:
    Male
    Female
    Copy of birth certificate is
    attached or has
    been submitted
    Yes
    No
    Previous employment and membership information
    1. Have you ever contributed to a Louisiana public retirement system?
    Yes
    No
    Name of system____________________________________________________________________________
    2. Did you withdraw your contributions when you left previous employment?
    Yes
    No
    3. Please indicate the position(s) you previously held:
    Position Years employed
    Employer
    _____ Teacher, professor, instructor From_________________ To_________________
    _______________________________________
    _____ Custodian, school bus driver From_________________ To_________________
    _______________________________________
    _____ School food service worker From_________________ To_________________
    _______________________________________
    _____ Other__________________ From_________________ To_________________
    _______________________________________
    4. If you withdrew retirement contributions before 1978, provide TRSL membership number if known. _____________________________
    5. If you contributed to another Louisiana public retirement system, do you wish to apply for reciprocal recognition of retirement credit between
    systems or actuarial transfer of funds and retirement credit to TRSL?
    Yes
    No
    00-2
    Applicant’s signature (Do not print or type)
    Date signed (mm-dd-yyyy)
    Signature of employer’s authorized representative (No facsimile accepted) Date signed (mm-dd-yyyy)
    Title
    Employment Status
    Full-time
    Full-time equals __________ hours per day.
    Part-time
    Annual full-time earnings $________________________
    Unclassified (if applicable)
    This employee will work __________ hours per week.
    Applicant is being enrolled in: Basis of employment
    Regular Plan
    9 months
    10 months
    Plan B
    11 months
    12 months
    For what percent of the
    first year will the applicant
    be employed?
    ___________________%
    Are you a U.S. citizen?
    Yes
    No If not, what type of visa do you possess? ________________
    !
    !
    Date of employment
    _____ / _____ / _________
    mm-dd-yyyy
    Date of birth
    _____ / _____ / _________
    mm-dd-yyyy

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