Senator Rusty Black
Courtesy Resolution Fact Sheet - Retirement
First, please give us your name, address, phone and email address.
Name:
Email address:
Phone:
Address:
City:
State:
Zip Code:
Now we need information regarding the resolution.
Date Resolution Needed: (mm/dd/yyyy)
Name of retiree:
City of residence:
Date of retirement:
Current position:
Previous position(s):
Current place of employment:
Years of service at current place of employment:
Special duties, assignments or accomplishments:
Former place of employment:
Number of years:
Position(s) held:
Community service, memberships:
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Names of family members and their relationship to honoree:
Other pertinent information:
Mailing instructions:
You agree with the terms and conditions.
Mailing instructions are required