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F234 NYCERS USE ONLY Mail completed form to 30-30 47th Avenue 10th Fl Long Island City NY 11101 Agency s Employee Status Change Notification This form is to be completed by any agency to notify NYCERS of a status change for an employee who is ALREADY a NYCERS member. THIS FORM MUST BE COMPLETED BY THE AGENCY ONLY AND SIGNED BY THE AGENCY ON PAGE 2 EMPLOYEE INFORMATION NYCERS Member Number Last 4 Digits of SSN Title First Name Title Code M. Is on an approved leave for check one Medical Child...
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Long Island City, NY is a neighborhood in the borough of Queens in New York City.
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