State of Connecticut

Attachment to:
Comptroller's Memorandum 2001-57
October 4, 2001

REQUEST FOR INFORMATION REGARDING STATE EMPLOYEES IN THE RESERVES
OF THE ARMED FORCES OF THE UNITED STATES

 

Name Of The Employee:



Employee Number:



Social Security Number:



Home Address & Telephone Number:








Name, Address & Telephone Number Of Any Contact Person For The Employee:






Health Insurance Coverage:



Branch of Service:


Employing Agency & Contact
Person In That Agency:





SEND TO: 
Office of the State Comptroller
Policy Services Division
55 Elm Street, Room 221
Hartford, CT 06106
Attn: Carolyn Mercier
Fax #: (860)-702-3441

 

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