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Service Record Request Form

Thank you for submitting a request for your Service Records, please complete this form below. Required fields marked with an asterisk *

If you have any questions please do not hesitate to email [email protected]

HR may need to contact you regarding your employment or for further clarification of your request, please enter your Contact Information below:

First Name*

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Last Name*

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First and Last Name used during employment, if different from above.

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Email Address*

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Mobile Phone*

Number Required

Social Security Number*

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Which of the following position(s) did you have while at NYOS Charter School? Please include any of the following that apply: Teacher, Substitute Teacher, Educational Assistant, Administrator, Auxiliary Staff: *

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What was your Start Date?*

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What was your End Date?*

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If you would like service records to be faxed or emailed to an individual or organization, please provide the fax or email address

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If you would like service records to be mailed to an individual or organization, please provide the address

Street Address

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City

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Zip/Postal

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