PERS Seminar/Session Registration Form

Complete the form below to register for the Full-Day Seminars Wednesday, November 06, 2019, in Hattiesburg. A confirmation page will be provided after you click the "Register" button.

* Required field

 Last Four Digits of Your Social Security Number*secured
 
Birth Date (mm/dd/yyyy)
First Name*
MI
Last Name*
Mailing Address*
City*
State*
Zip*
E-Mail
Employer Name
Work Phone
Home Phone
Cell Phone
Special Assistance
Planned Retirement Date* (mm/dd/yyyy)
Combined Unused Personal and Medical Leave
Days
Terms as Elected Official (If applicable)
Guest/Spouse Name (If applicable)
If guest/spouse is a PERS member, register separately to ensure receipt of estimate.