Follow the steps to successfully complete the form.

1. Click the ‘Get Form’ button to obtain the form and open it in your selected editor.
2. In Section 1, provide your Employee Information by filling in your last name and first name. Ensure accuracy in spelling as it will be used for identification purposes.
3. In Section 2, fill out your Employer Information. This includes the name of your department, term of appointment (indicate if it is permanent or temporary), and time base (full time or part time). Make sure to provide your date of birth and CalPERS identification number (CID) if applicable.
4. Next, provide your Position Title and indicate the expected duration of your temporary appointment in months if it is less than a year. If part-time, state the fraction that represents your working hours compared to full time.
5. Next, indicate the reason for exclusion from CalPERS membership by checking the appropriate box corresponding to your employment status. If applicable, provide a concise explanation in the space provided.
6. Complete the certification section by signing as an employee and having a certifying officer also provide their signature. Ensure all dates are correct.
7. Review the form for accuracy. Once confirmed, you can either save your changes, download it, print, or share the completed form as required.

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