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Get CA PERS-BSD-369-S 2019

Te. For detailed instructions on how to complete this form, please refer to the publication Service Retirement Election Application (PUB 43). Section 1 Please provide your name as it appears on your Social Security card. Information About You Your Name (First Name, Middle Initial, Last Name) Social Security Number or CalPERS ID Address City State ( Birth Date (mm/dd/yyyy) ZIP Country ( ) Daytime Phone ) Alternate Phone Email Address Section 2 Please enter the last day you were on.

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