Medicare Tax Eligibility Form - River Parishes Community College (Page 4 of 4) in pdf

Medicare Tax Eligibility Form - River Parishes Community College Page 4

RIVER PARISHES COMMUNITY COLLEGE

SELECTIVE SERVICE COMPLIANCE

Selective Service System Registration: In accordance with R.S. 42.33 (Act 1987, No. 581,

Section 1.), an individual shall be ineligible for employment or appointment in an unclassified

or classified position (faculty or staff) with the Board or institutions within the LCTCS System

if he is between ages 18 and 25 and is required to register under Section 3 of the Military

Selective Service Act (50) U.S.C. App. 453) and has not.

Failure to register is a felony and subjects the offender to penalties and loss of benefits such as:

federal and many state and local jobs, student financial aid, federal job training programs,

eligibility for U.S. Citizenship, etc.

I am registered with Selective Services and my registration

number is ____________________.

I have not registered with selective services because I am

exempt from registering due to a bona fide reason such as a female,

person with a disability or another federally approved reason.

___________________________

______/______/_______

___/____/_____

Signature

Social Security Number

Date

Office of Human Resources ● 7384 John LeBlanc Blvd. ● Gonzales, LA ● (225) 675-8270

Medicare Tax Eligibility Form - River Parishes Community College Page 4