PRIOR SERVICE FORM
(Please print all information on form.)
DATE:  ________________________________________
I, ___________________________________________________, hereby request information as to the amount of service
time that I have accrued with the Virgin Islands Government. I estimate my years of service to be __________________.
Date of Birth _________—__________—_________________           Age ___________________
(mm)              (dd)                  (yyyy)
What is the purpose of this request?
K For repayment of contributions
K I'm eligible for retirement
If eligible for retirement, what is your projected retirement date?_____________________________________________
I HAVE WORKED IN THE FOLLOWING DEPARTMENTS:  (If you need additional space kindly attach a separate sheet.) 
DEPARTMENT 
POSITION TITLE 
PERIOD OF SERVICE
Military Time _______________________________________________________________________________________
_____________________________________________
Employee No. ________________________________
Signature of Member
Social Security No. ____________________________
Telephone No.________________________________
Mailing Address _____________________________________________________________________________________
_____________________________________________________________________________________
GERS-BEN107  Rev 06
(Print Name)
GOVERNMENT EMPLOYEES RETIREMENT SYSTEM
3438 Kronprindsens Gade, GERS Complex - STE 1, St. Thomas, VI 00802-5750 • (340) 776-7703 • Fax (340) 776-4499
3005 Orange Grove, Lot #5, Christiansted, St. Croix, VI 00820-4313 • (340) 773-5480 • Fax (340) 773-5497