ORS 3% Healthcare Refund
Former Employee Contact Information Form
If you are a former Cros-Lex employee who was employed between July 2010 and September 2012 and your name, address or other contact information has changed since your time of employment, please complete this form. In addition, we recommend that you confirm and/or update the contact information in your MI Account. This will help ORS and the District process the refund. At this time, no further action is required.
Do not fill out this form if you are a current Cros-Lex employee.
First Name *
Your answer
Middle Name (Optional)
Your answer
Last Name *
Your answer
Former Name (If you were employed under a different name from 2010-2012)
Your answer
E-Mail Address *
Your answer
Phone Number
Your answer
Last 4 digits of Social Security Number *
Your answer
Mailing Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Commments
Your answer
Submit
Never submit passwords through Google Forms.
This form was created inside of Croswell-Lexington Community Schools. Report Abuse - Terms of Service - Additional Terms