Retirement Certificates

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

Scott M. Schmerelson