Requests

Please submit this form if you want the Board District 3 office to prepare a certificate for district staff.

Important:
Please allow at least 2 weeks for processing of the request
Retiree Name*

Please submit the retiree's name as you want it displayed.
Pronoun*
Please provide the pronoun this person prefers
Years of Service*

How many years has this person worked for LAUSD?
Titles and Positions*
Please list the Job Titles the person has had and the school site, if applicable
Retirement Date*
MM slash DD slash YYYY

Please provide the date when the person will retire or that you would like displayed on the certificate.
Due Date*
MM slash DD slash YYYY

Please provide the date when the certificate should be ready.
Special Qualities, Outstanding Achievements, Award*
Please describe the qualities that this person had that they will be remembered by, any of their outstanding achievements or any important awards they received.
Submitted by*

Please include the name of the person submitting the request.
Email*
Phone*
Let us know where you want us to send the certificate

Please fill out this form to request a certificate for a community member that deserves recognition.

Important:
Please allow at least 2 weeks for processing of the request.
Complete Name of Person, School or Organization receiving Certificate*

Please provide the name of the person as you want it displayed on the certificate
Reason for Recognition*
Please provide the reason why this person is being recognized
School Name

Please provide the name of the school with whom this person is associated
Date on Certificate*

Please provide the date that you would like to see on the certificate.
Due Date*
MM slash DD slash YYYY

Please provide the date when the certificate should be ready.
Submitted by:*

Please include the name of the person submitting the request.
Email*
Phone*
Please let us know where you want us to send the certificate.

Scott M. Schmerelson