Service Awards - Previous Employment Verification

This form is to be used for employees who have employment service credit with another UC, DOE (Department of Energy) Lab, or State of California service. 

Directions:  The employee should complete the form with all relevant information, print & sign, and then mail it to their former employer.  The section in yellow is to be completed by the employee - please fill in the mailing address of your current department's payroll processor.  Your former employer will then mail the completed form directly to them.

Click Here to download the form