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Home My WebLink AboutReel_0024D "~.....,,,~..lJI!fJ(~_ "" 'H - .. .l><f . '. I~ l!Ifi ""'Wi , , /. .:lr. .\~~. ',';. ~t....:. ~...,:,...,,#~..~; . r----- . .. S. F. No. '7646-(Rev. 11-:l2)-1l-:l2-10M. 321JU. WASHINGTON STATE EMPLOYEES' RETIREMENT SYSTEM (LEAVE BLANK) EMPLOYEE'S PERMANENT RECORD Member No........................................_ Date ot entry...................................... To Be Completed. During the First 30 days ot Employment by All Employees in All Eligible Positions OrJg. member...... New member...... TO THE RETIREMENT BOARD: . As a condition of my employment under the requirements of the State Employees' Retirement Act r submit the following information: SECTION A. HISTORY . . 1. Name..ll..m.__711..ag f_..~L/.i.E.!f.["_._..____..;rg,t...?L__ __.______.._____ (La") (First) C' (Middle) (Malden. U marrIed) 2. Permanent~ddress___._____.__.._..___...____._____ -'Ji.../...tJ...1...I!..c...!!.J7J__"1lI.i"..tf.. r __ ~__ C/'/72__ . . - "(Street)" '(City)' ,- ,,' (County)' , " (State) . . . --rJ-F".r-: (',/1/7)(1/ PC"'F"~ ~ Vlr7tC4 3. (a) r began my present employment wlth-9_$c_..._._"__.__.._._____.__.2~__..____L_'____'_____..- ' 'I'-' Ii '~J -, , (Name ot department. commission. agency) i aLL6"..liYl .Jl:.f....!!._M_ on the__A'__Q__.day oL::s[j,d_.k-}L.__~.______. 19.!J-'; .., (b) Title. of position......_/J..../LL/t..lLL'\..__.___.__..__..____....___.___..___.._..____--'.__...._.__~.___...........,..: (c) (If applicable) r am also employed by____.__ .....-....-.-.(N-;;;;;~-~i-d-;,;;;;;;,-._~t.-.;;;;;:",.J;i,;;;~...-.---.- Pres~nt rate of monthly compensation: MaJntenance Allowance Where ServJce Was Rendercd PERIOD OF SERVICE Namo ot Deportment. Commlnlon or Agency Title ot POlltlon lIcld M!c'W~:n\r. EndlnlJ Len9'th of Period Mo. Doy Yr. . (Months) 19 19 19 19 19 19 19 19 r am.a meniber of or receiving benefits from the following retirement plan or plans: ---------------~._---~_.-. 7.' S-oclal S~:rit;-~o._.f-~~q-=l;J:~is=--.--..-... 8.: Check by (X)-Marital status: Single___ Married:::;;'" Wfdowed_ Divorced__ :." . 9. Check b)' OQ-Sex: Male.~__ Female_ ";. .. .....,! :: 10. Date of birthIlLl?L"'__Z____IZLJi!:.._ Place ot birth--C_6.:L'A.1.~Cyll!".:t2'LLL_ ..., tf/1.. : Ufonthl jDAYJ (Y"ar) (City) (C6unty)..' (St.Ato~ IT"T' ""IIITING I"L""T ~ 01.'1'11"1"', WAIIUNQTOM . ~ j ".." . .FO">: .: ..', ,".',. ". '0" '..;' .:.> .' ..,.................../> ..'..... i.:'i.o',i. i'.. ...."X..ii".'.......'....i.. ," ,./ii.{ ........../.:....{.. /' "; ";..' :.. "'. '.:'.' .,., I 1 I I 1 I I'~I I I I I I I I I I I I I ~I I I I I ~ .... ~ i~~ ;,; ."~ I " 0-;:,0 al ~e~ 11111111111111.lllll"l Jill I ~ .g ~~~ li" .. , ,'ii! .,,'- :.3 " Ir<LlJ1IJIJI.IJ...." .1... .'..." I I :.a. ,;11 ,C1l :'a .8 ~ '.0" I:.:: JIII/I:/IIIII illl I I " >>, g "" -" ~ ~ I '. 1J.,a , ] I 1::'" 0-" :s o.~ ;::1;:: 0... : '" ... 5 '" '" ;:: '" '" ::l ::l ::l ::l '" '" ::l '" '" ::l ::l ::l ::l ::l ::l ::l ::l ::l ~u ,- ;c' ~ ..'" 1- - .8~' , J. .. i J:l fj ~g !i ~ ,.,! 0 El.g. '" Il : ~ .. Slal 0 0 f5 ~ 1: ~ . Ill. ~. ~~ 'U.,Q fl ,,-" ':,:.'~:~ .. . ::l ::l ;:: '" ;:: ::l ::l ::l ::l ::l ::l ::l ::l ::l ::l ::l ::l ::l ::l ::l ::l ::l ::l ::l ::l ~ '" . .. ..,. - ~.>: ~"~ ~~ 1) ~ ~'.,....f tl I;lJ '. r. ~ /:1w ;5~ 'Ill 0 ~ . ., ~ 'B' :- :0'8 .. (Jl w~ lil.. 0 g I ~ 0" '." ~.'" ~ 1) ","'c=' .,~ " a.. 0: ~~ : Jf'g, ""il 2 '0= -"0. ;;!fl.i . ., ~.~ " . u ;; .. ~ t r; ... I, .' ~-" (Jl H ' ::l $ :I" ~ " ~' '~ ~w ]1 ~ ... 0 ~: 0 (Jl t:: ID ~ 0.'- r4/~ . r.. ... go . , <" '. 0 ~ u I z'" '"So, ,,' z s~ " . 0 ~ U o '..il . ~ E'" lOo ~ EJs] s Iol ~ . ! i~ li ! 'c/) .G.I -- --~ ,.~ j~ a oS ,'~. ~ ~ i a C1b ~ ~ <... f'l~" g ..' 11 o..~ ~ Il ~. ~ ~~ .~ .. II P< 'O:! oS ~ ~ -:: '<1 ~ 0 ~ tl - I-- . ~ 0 ;::: 0 8: ~ .. I i~ ii '" ~ .~ ~ 8 s , ".~ '0 :l J. 0. t 0 1l Jl 0 .... .:1 ~ .... - N .. of' .., .. .. .. '" " 0 Motola H9 . ::: ::: ::l :!: ~ :e ~ ::: ::l ;; " l:l .,. 11 o. N " , : I , I : :..',"'i .....:>i... . .' ... '. .....' :.:( ..',:",'i/:.,' "',:: ":':,...,.::..:.... ~ ":."'}i.' ..;,'ii.... ,,(,.<...., .'.'" c",,'" , ' tM~. r ~r , " ~~.~""'I .. '." ',\ .~ ~_. ,_ ,',~. ,L.- ~.', _. '" I!'~,'" '~;:-( : >'~" ~__~ ~ ' "-'--~~", ..~_._- '-'-, - - -- "'. ....... _. vr "fl'~',lIl ~-;-; '. "":~':',. ~'l '," __., /'1. ~"~ ''':.,~:i__".~___~. ~ r..----~.-.-"