State University of New York
Retirement Program History Sheet

This form is used to communicate prior participation in a retirement system.

Name:
     
SS#:
     
Phone:
     
Title:
     
Campus:
     
 

1.	Have you ever been a member of the SUNY Optional Retirement Program?       	 0 Yes  0 No

Name Of
Campus
Title of
Position
Full or 
Part Time
From
Mo/Day/Yr
To
Mo/Day/Yr
Contract Number
(If Known)















2.	Do you currently own a TIAA-CREF, AIG, ING, or Met Life basic retirement        0 Yes  0 No 
annuity contract to which employer contributions were made?						     

Name Of Vendor
Contract Number
Contributing Employer









3.	Are you presently a member of the New York State Employees' Retirement System
      (ERS) * or the New York State Teacher's Retirement System (TRS)? 	          	             0 Yes  0 No
     
Name Of Retirement System
Membership Number
Membership Date








 
4.  Are you presently receiving a retirement benefit from any public Retirement System 
    of New York State?									        	0 Yes	  0 No

Name of Retirement System
 Date of Retirement




Signed:

Date:
     
		 										(mm/dd/yyyy)

* If yes, and you desire to join the ORP but have less than ten years of service credit, contact your Human Resources office and request 
Form ORP-4.  Attach that form to this one when sending. 
 
ORP-3			Rev. 5/08