Request for Retirement Certificate

Part A Requestor's Information

Requestor's Name:

Requestor's Telephone:

Requestor's E-Mail Address:

Requestor's Campus Address

Requestor's UDDS:

Requestor's Department Name:

Certificate Distribution:

Pick Up Send

Part B Retiree Information

Name as it will appear on the certificate:

Last Name:
First Name:
Middle Int:

Classification:
Classified Unclassified
Gender:
Male Female

Retirement Date: (mo/day/yr)

Certificate from the Governor's Office: Employees who have 20 or more years of service can receive a certificate of appreciation from the Governor's Office. Please check here if you want this certificate:
Years of UW Service:

Combined Years of State and UW Service:

Does this person want to continue to have access to campus facilities, including their DoIT email account? Yes No
If you check yes to the above question, the employee will retain privileges as outlined in http://www.ohr.wisc.edu/polproced/UPPP/2001.htm "Privileges Retained After Retirement" and in the brochure entitled "Privileges for UW-Madison Retirees". There is no need to send an additional email to retiredID@ohr.wisc.edu. If you have questions or would like a copy of the brochure, please contact Margy May at the Academic Personnel Office, 166 Bascom Hall, mmay@ohr.wisc.edu, 263-2431.

Date Certificate Required:
(mo/day/yr)

Comments:

Please allow 30 days to process your request. If you are picking up the certificate, you will be notified by email when it is ready. Certificates may now be picked up at Room 166, Bascom Hall.