APPLICATION TO PURCHASE OTHER GOVERNMENTAL SERVICE

I hereby make application for retirement credit for other governmental service performed by me in accordance with MCLA 46.12 a(9) and the Genesee County Retirement Ordinance, Section 18, and my union contract, if applicable.  I have attached all related documentation, including the completed Employer Questionnaire Form(s).

 

Name (please print):

 

Social Security #:

Employee Department/Telephone # and Extension:

 

Employee Address:

 

 

Signature:                                                                                                                             

Date: