PREVIOUS PERIODS OF SERVICE WITH
OTHER STATE AGENCIES
(PRINT) LAST NAME
FIRST NAME
MIDDLE INITIAL
HAVE YOU HAD ANY PREVIOUS PERIODS OF SERVICE WITH OTHER STATE AGENCIES? (See Reverse Side for a Listing of Commonwealth
Agencies)

YES

NO
IF YES, LIST THOSE PREVIOUS PERIODS OF SERVICE BEGINNING WITH YOUR MOST RECENT EMPLOYMENT BELOW:
NAME OF AGENCY OR BRANCH OF STATE GOVERNMENT
FROM (MONTH, DAY, YEAR)
TO (MONTH, DAY, YEAR)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
NOTE: ALL MARRIED FEMALE EMPLOYEES. If you have worked in another agency under your maiden
name, place your maiden name beside the name of the appropriate agency.
SIGNATURE
DATE
\\financeserver\hrfr\LHarrison\Benefit Orientation Checklists & Forms\Service with Other State Agencies Form.doc
Rev. 09.20.10
COMMONWEALTH AGENCIES
Agencies covered under the Governor’s jurisdiction:
▪ Aging
▪ Insurance
▪ Agriculture
▪ L&I (Labor & Industry)
▪ Banking
▪ LCB (Liquor Control Board)
▪ Civil Service Commission
▪ Lt. Governor’s Office
▪ Community & Economic Development
▪ Milk Marketing Board
▪ Corrections
▪ PA Public Television Network
▪ DCNR (Conservation & Natural Resources)
▪ PEMA (Emergency Management Agency)
▪ DEP (Environmental Protection)
▪ PennVest
▪ DMVA (Military and Veterans Affairs)
▪ PMRC (Municipal Retirement System)
▪ DOT (Transportation)
▪ Probation & Parole
▪ Education
▪ PSERS (Public School Employee Retirement
System)
▪ Executive Offices
▪ PUC (Public Utility Commission)
▪ Fish & Boat Commission
▪ DPW (Public Welfare)
▪ Game Commission
▪ DOR (Revenue)
▪ DGS (General Services)
▪ Securities Commission
▪ Governor's Office
▪ State
▪ Health
▪ SERS (State Employees' Retirement
System)
▪ Historical & Museum Commission
▪ State Police
▪ HRC (Human Relations Commission)
▪ State Tax Equalization Board
\\financeserver\hrfr\LHarrison\Benefit Orientation Checklists & Forms\Service with Other State Agencies Form.doc
Rev. 09.20.10