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: 7 digits-required

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:

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:

Empl ID:

Empl Record:


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 "Privileges Retained After Retirement" and in the brochure entitled "Privileges for UW-Madison Retirees and Emeriti." There is no need to send an additional email to If you have questions or would like a copy of the brochure, please send an email to


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 21 N Park Street, Suite 5101. If you have questions, please contact Donna Seelye (890-3183).