Request for Retirement Certificate Requestor's InformationRequestor's Name* First Last Requestor's Phone*Requestor's Email* Requestor's Campus Address*Requestor's UDDS*7 digitsRequestor's Department Name*Certificate Distribution*Pick upSendRetiree's InformationName*Name as it will appear on the certificate. First Middle Last Job Title*Job Title as it will appear on the certificateMailing Address*Address where certificate should be mailed.Date of Birth* MM DD YYYY Retirement Date* MM DD YYYY 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. Do you want this certificate?YesNoYears of UW Service*Empl ID*Empl Record*Combined Years of State and UW Service*Does this retiree want to continue to have access to campus facilities, including their DoIT email account?*If you answer yes to this question, the employee will retain privileges as outlined in the policy Privileges Retained After Retirement, and in the brochure Privileges for UW-Madison Retirees and Emeriti. 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 send an email to email@example.com.YesNoCommentsPlease 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 be picked up at 21 N. Park Street, Suite 5101.If you have questions, please contact Donna Seelye at 608-890-3183.