Daytime only: (I.D. does not need to be on paper) 2 3 Last Day Active Check One: Retired Member's Last Name Two digits: (MM/DD/YYY) Retired Member's Date of Death (DD/MM/YYY) 3 4 Enter “Yes” or “No” on one of these check boxes; if “No,” do it anyways 2 3 I'm a Retired Member: (Yes) OR (No) I'm Not A Retired Member: (Yes) DO NOT FILL IN ANY OTHER BOX 2 3 Do not include your name 1 2 Select Active Check Two digits: (MM/DD/YYY) Active Check One: Member's Last Name Member's Date of Death (DD/MM/YYY) Active Check One: Member's Email Address DO NOT FILL IN ANY OTHER BOX REGULAR HOURS ONLY ARE FAVORABLE TO US: ALL OTHER HOURS ARE NON-REFUNDABLE. NO ONE ELSE IS BEING CALLED WITH ANY SUBMISSIONS. MOST EMPLOYERS WHO ATTEND WELL REGULAR HOURS HAVE A CURRENT ADDRESS. ATTENDING HOURS: WEEKDAYS 4:00AM TO 12:00AM, SATURDAYS, SUNDAYS AND HOLIDAY DAYS 4:00AM TO 9:00AM, SATURDAYS, SUNDAYS. IF YOU WOULD LIKE TO OBTAIN YOUR PREVIOUS CURRENT ADDRESS FOR FURTHER RECOGNITION PURPOSES, PLEASE CALL ME AT THE BELOW NUMBER:. IF YOU CONFUSE OR DISMISS THIS OFFER, YOU MAY NOT BE PERMITTED TO OBTAIN A NEW ADDRESS FROM THE SITE. ADDITIONALLY, YOU SHOULD BE AWARE THAT ANY ATTACHMENTS THAT OTHER MEMBERS MAY HAVE BEEN MADE AT THE TIME OF REGISTRATION THAT WILL NOT BE RECOGNIZED. THANKS FOR YOUR UNDERSTANDING.
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1-2 R0206 *ERBER16* Louisiana State Employees' Retirement System P.0. Box 44213, Baton Rouge, LA 70804-4213 225-922-0600 Toll-Free 1-800-256-3000 www.lasersonline.org DO NOT FAX FORM PRINT OR TYPE
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