Retirement Appointment Request

Full Name*
Badge/Employee Number*
Address*

Street Address

Address Line 2

City

State

ZIP Code
Email*
Phone*
Date of Last Estimate

MM slash DD slash YYYY
Retirement Month*
Retirement Year*
Total vacation remaining at retirement (in full weeks)
Accumulated sick leave at retirement, in days (if applicable)
Have you worked since January 1 of this year without any breaks in service?*
- Yes
- No
If you have answered "no" to the above, please explain.
What total amount of time in full months (if any) has been lost due to breaks in service for suspension, discharge, exhausted sick leave, etc
Marital Status*
- Single
- Married
Select a retirement option (this election is non-binding)*
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