Senator Mike Bernskoetter


Courtesy Resolution Fact Sheet - Retirement

First, please give us your name, address, phone and email address.

Name:


Address:


City:


State:


Zip Code:


Phone:


Email address:



Now we need information regarding the resolution.


Date Resolution Needed: (mm/dd/yyyy)



Name of retiree:



City of residence:



Current place of employment:



Date of retirement:



Current position:



Previous position(s):



Years of service at current place of employment:



Special duties, assignments or accomplishments:


Former place of employment:



Position(s) held:



Number of years:



Community service, memberships:
Names of family members and their relationship to honoree:
Other pertinent information:
Mailing instructions:




 

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