GVI Employee Number Request

1

Name of person completing/submitting this form:* This field is required.

First Name

Last Name

2

Email of person completing/submitting this form:* This field is required.

example@example.com

3

Select your agency/department:* This field is required.

4

Is this a new number request for the Senior Community Service Employment Program (SCSEP)?* This field is required.

YESNO

5

Is this new number request for a retiree to return to GVI service?* This field is required.NOTE: Falsification of information on this form is grounds for corrective action, up to and including termination of employment.

YESNO

6

Is this a request for a dual employee number?* This field is required.Note that dual numbers are only for current active staff who's been authorized to also work within another agency.

YESNO

7

Is this a request for five (5) or more employee numbers?* This field is required.For example, 5 or more "Per Diems" and/or Summer Students?

YESNO

8

Name of person needing the new number:* This field is required.

First Name

Last Name

9

Please enter their names and Social Security numbers:* This field is required.Use this format: Last Name, First Name : SSN

10

What's their Social Security Number?* This field is required.

11

What is their original employee number?* This field is required.

12

What position will they fill?* This field is required.

13

What is their anticipated start date?* This field is required.

Date

14

Upload your agency head's approval letter authorizing this rehire:* This field is required.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

15

Upload GERS' letter certifying that the retiree has met the retirement criteria under ACT 8560:

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Select files to upload

Max. file size: 10.6MB

16

Upload your approved request from DOP Director:* This field is required.

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Max. file size: 10.6MB

17

Upload your approved Reentering Retiree Request:* This field is required.

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Max. file size: 10.6MB

18

Attestation* This field is required.I attest to the following: • That I am an officer with the authority to make this request for a reentering retiree’s new employee number; • That the retiree's reemployment under this program shall be on a temporary basis only; • That all the information I have provided in this request is true, complete, and accurate to the best of my knowledge and belief; • That it is my responsibility to read any applicable statutes, regulations, and policies governing reentering retirees; and • That it is my duty to abide by Act 8560, any other applicable statutes, regulations, and policies in the hiring of any reentering retiree.

Yes, I attest to the statements above.

19

Attestation (2)* This field is required.I attest to the following: • That I am an officer with the authority to make this request for an employee number; • That all the information I have provided in this request is true, complete, and accurate to the best of my knowledge and belief; • That this is NOT an employee number request for a reentering retiree; • That it is my responsibility to read any applicable statutes, regulations, and policies governing employment and requests for employee numbers; and • That if I falsify any information in this request, I am subject to corrective action up to and including termination of employment.

Yes, I attest to the statements above.

20

Sign this application using the following format: "/s/ first name & last name"* This field is required.Typing your name below is the equivalent of signing this document.