TO BE COMPLETED BY EMPLOYEE
TO:
______________________________________________________________
{Insert name of former University of California or State of California agency}
______________________________________________________________
{Address}
RE:
University of California or State of California Employment Service from ____________ through ___________
month/year
month/year
I recently was employed by the University of California, Irvine and need verification of my prior UC or state of
California employment service. Please research your records and verify my service for vacation and sick leave accrual
purposes.
I have read the Privacy Notification {on reverse of this form} and hereby authorize the release of the required
information to the University of California, Irvine.
____________________________________________
Signature
__________________________________________
Date
____________________________________________
{PRINT} Name
_________________________________________
Social Security #
Date of Birth
______________________________________________________________________________________________
Street Address
City
State
Zip Code
_____________________________________________________
Previous name, if applicable
*************************************************************************************************
TO BE COMPLETED BY PRIOR UC OR STATE AGENCY
RE: ________________________________________
Name
_____________________________________
Social Security #
Birthdate
SERVICE INFORMATION:
1
_______________________________________
Employment Date
Separation Date
3
Percentage of Time:
4
Periods of leave without salary: {including military leave}
___________
2 _____ years ____ months ____ days
Total Service {as of date of separation}
Full Time __________
Part Time _________
From: _____________Through: ____________ From: ____________Through: _____________
5
Accumulated leave balances to be transferred: Sick Leave _____ hours / Vacation _____hours
(Vacation hours are only transferable within the UC system)
_______________________________________________________________________________________
Signature of UC or State agency official
Title
Date
Mail to:
University of California, Irvine
Payroll Department
Irvine, CA 92697-1055
FEDERAL PRIVACY NOTIFICATION
The State of California Information Practices Act of 1977 requires the
University to provide the following information to individuals who are
asked to supply information about themselves: The principal purpose for
requesting the information on this form is to verify state of California
employment service. University policy authorizes maintenance of this
information. Furnishing the information requested on this form is
voluntary. There is no penalty for not completing the form. Information
furnished on this form May be used by various University departments for
verification of vacation and sick leave accrual. Individuals have the right
of access to this record as it pertains to themselves. The official
responsible for maintaining the information contained on this form is the
Personnel Manager, Human Resources Office, University of California Irvine, 250 Berkeley Place, Irvine, CA 92697-4600.
STATE PRIVACY NOTIFICATION
Pursuant to the Federal Privacy Act of 1974, you are hereby notified that
disclosure of your social security number is voluntary. This record
keeping system was established pursuant to the authority of The Regents
of the University of California under Article IX, Section 9 of the
California Constitution. The social security number is used to verify your
identity.
Retention: UAT