Instructions Please print or type in dark ink 2025

1. Click ‘Get Form’ to open the application for exclusion from membership in the editor.
2. Begin by filling out the EMPLOYEE INFORMATION section. Enter your SOCIAL SECURITY NUMBER or PERA ID NUMBER, FIRST NAME, MI, and LAST NAME. Ensure all required fields are completed in bold italics.
3. Provide your ADDRESS TYPE by selecting either PERMANENT or TEMPORARY. Then, fill in your STREET ADDRESS, CITY, STATE, and ZIP code.
4. Input your HOME TELEPHONE NO., BUSINESS TELEPHONE NO., EMAIL ADDRESS, DATE OF BIRTH, CITY OF BIRTH, and GENDER (select MALE or FEMALE).
5. Review the EMPLOYEE CERTIFICATION statement carefully. Sign and date the form to confirm your application for exclusion from membership.
6. Complete the CURRENT EMPLOYMENT INFORMATION section as required by your employer. This includes DATE EMPLOYED, NAME OF EMPLOYER, CURRENT POSITION, and EMPLOYER NUMBER.
7. Ensure that an authorized representative from your employer fills out the EMPLOYER CERTIFICATION section with their signature and date.

Start using our platform today to easily complete your application for exclusion!