1. A. Nominating Petition. Nominations will be submitted on a form substantially in compliance with the following.

   We the undersigned OGB enrollees are retired teachers or retired school employees/retired state employees and hereby nominate ______________ for membership on the Office of Group Benefits Policy and Planning Board.
   Signature	Printed Name	Last 4 of SSN	Agency	Date
   1.
   2.
   3.
   4.
   5.
   6.
   7.
   8.
   9.
   10.
   11.
   12.
   13.
   14.
   15.
   16.
   17.
   18.
   19.
   20.
   21.
   22.
   23.
   24.
   25.
   I hereby certify the persons signing this petition are retired teachers or other school employees/retired state employees and OGB retired enrollees as of the specified nomination date. _________________________________________________________ OGB Chief Executive Officer or his/her designated representative

Authority Note

AUTHORITY NOTE: Promulgated in accordance with R.S. 42:801(C) and 802(B)(1).

Historical Note

HISTORICAL NOTE: Promulgated by the Department of Treasury, Board of Trustees, State Employees Group Benefits Program, LR 7:50 (February 1981), amended by the Office of the Governor, Division of Administration, Office of Group Benefits, LR 41:348 (February 2015), effective March 1, 2015, LR 41:2352 (November 2015), effective January 1, 2016.