ORS 3% Healthcare Refund
Former Employee Contact Information Form
If you are a former Memphis Community Schools 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 Memphis 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
Email Address *
Your answer
Phone Number
Your answer
Last 4 digits of Social Security Number *
Your answer
Street Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Comments
Your answer
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