PARI-MUTUEL EMPLOYEES GUILD OF CALIFORNIA, SEIU LOCAL 280

1838 East Huntington Drive, Duarte, California 91010-2672

(626) 301-7900 - FAX (626) 301-7960

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R E T I R E E A P P L I C A T I O N F O R M

PLEASE PRINT: DATE: _______________________

NAME: _______________________________________________ SOCIAL SEC. # ____________________

BIRTH DATE ____/____/____ LAST DAY WORKED ____/____/____ DATE RETIRED ____/____/____

ADDRESS: __________________________________________________TELEPHONE #: _______________

CITY: ___________________________________________ STATE: ____________ ZIP: ______________

SPOUSE’S NAME ________________________________ SOCIAL SEC # ____________________

SPOUSE’S BIRTHDATE ___/___/___

RETIREE’S SIGNATURE _________________________________ DATE ____\____\____

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OFFICE USE ONLY

RETIREMENT STATUS

(Circle correct status)

RETIREMENT RETIREE H & W UNION DUES STATUS

DISABILITY YES NO Active Retired

EARLY YES NO Active Retired

NORMAL YES NO Active Retired

DATE RECEIVED: ____/____/____ ACCEPTED BY: _______________________________________

COMMENTS:______________________________________________________________________________

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