Election for State Retirees To Be Employed Pursuant to Section 212

Re-employment application for rehired state unclassified retirees with earnings limitation if employee is younger than 65 years. Hiring department requests applicant to complete the form; the department returns the completed form to Human Resources.

Mobile Users

For the best experience in completing this form use a non-mobile device.

Using Firefox with PDF forms?

Make Adobe Acrobat the reader.

Completing the PDF Form

  1. Read through all pages of the document to find specific instructions if any
  2. Enter requested information into the form
  3. Print the form
  4. Get required signatures
  5. Scan a copy of the signed form for your records
  6. Send the original, completed, signed form to:         

Human Resources
120 Crofts Hall
North Campus

Need help completing the form?

Send email, phone or submit a question

Lissa Jasinowski

Retirement Administrator

State Benefit Services

Phone: (716) 645-4488

Email: lmt22@buffalo.edu

About the Issue or Your Comments

 
 
(We'd like to respond to you.)
(Required)

Form Facts

Form Type: Downloadable, PDF document

Requirements: Adobe Reader

Updated: 7/2017

Owner: Human Resources