Change of Name Form 1-07

Form 1-07
R062011
NAMECHG
DO NOT FAX FORM
PRINT ALL INFORMATION
www.lasersonline.org
P.O. Box 44213, Baton Rouge, LA 70804-4213
225.922.0600 · Toll-Free 1.800.256.3000
225.922.0612 (hearing impaired)
Change of Name
Member's First Name
Middle Name
Last Name
Today's Date
Social Security Number
IMPORTANT: Complete the entire form. Follow the specific instructions for each section. All dates should be in MM/DD/YYYY format.
SECTION 1: MEMBER'S INFORMATION
Member's Mailing Address
Daytime Area Code/Phone Number
City
State
Evening Area Code/Phone Number
E-mail Address
Zip Code
Member's Birth Date
SECTION 2: CHANGE OF NAME
Check one:
Active Member
DROP Participant
Name changed FROM
Retired Member
Beneficiary of a Deceased Member
Name changed TO
SECTION 4: MEMBER SIGNATURE
I hereby request that my name be changed and I have attached a copy of my SOCIAL SECURITY CARD showing the correct name.
Member's Signature
Date
Reset Form
1-07 R062011
RETAIN A COPY FOR YOUR RECORDS
NAMECHG Page 1 of 1