"Years of Service / Retirement Certificate Request Form" - Arkansas

Years of Service / Retirement Certificate Request Form is a legal document that was released by the Arkansas Department of Finance & Administration - a government authority operating within Arkansas.

Form Details:

  • Released on October 21, 2015;
  • The latest edition currently provided by the Arkansas Department of Finance & Administration;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Arkansas Department of Finance & Administration.

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OFFICE OF PERSONNEL MANAGEMENT
Administrator’s Office
STATE OF ARKANSAS
Department of Finance
1509 West Seventh Street, Suite 201
Post Office Box 3278
Little Rock, Arkansas 72203-3278
and Administration
Phone: (501) 682-1753
FAX: (501) 682-5104
www.dfa.arkansas.gov
M E M O R A N D U M
Office of Personnel Management
TO:
FROM:
DATE:
SUBJECT:
Years of Service Certificate
Official request for the following from the Office of Personnel Management:
10 Year Service Certificate
20 Year Service Certificate
30 Year Service Certificate
40 Year Service Certificate
Retirement Certificate
Employee’s Name:
Employee’s Preferred Name:
Employee’s Official Title:
Employee’s Dates of Service/Retirement Date for Above:
Select one:
Certificate
for pick up
by messenger mail
by US Mail
Agency/Institution Contact Name/Title:
Contact telephone/address information per certificate transmittal selection above:
Request MUST be submitted to the Office of Personnel Management at least two weeks prior to the date needed.
_______________________________________________________
_____________________
Agency/Institution Director/President/Chancellor/Designee Signature
Date
Years of Service/Retirement Certificate Request Form 10/21/2015
OFFICE OF PERSONNEL MANAGEMENT
Administrator’s Office
STATE OF ARKANSAS
Department of Finance
1509 West Seventh Street, Suite 201
Post Office Box 3278
Little Rock, Arkansas 72203-3278
and Administration
Phone: (501) 682-1753
FAX: (501) 682-5104
www.dfa.arkansas.gov
M E M O R A N D U M
Office of Personnel Management
TO:
FROM:
DATE:
SUBJECT:
Years of Service Certificate
Official request for the following from the Office of Personnel Management:
10 Year Service Certificate
20 Year Service Certificate
30 Year Service Certificate
40 Year Service Certificate
Retirement Certificate
Employee’s Name:
Employee’s Preferred Name:
Employee’s Official Title:
Employee’s Dates of Service/Retirement Date for Above:
Select one:
Certificate
for pick up
by messenger mail
by US Mail
Agency/Institution Contact Name/Title:
Contact telephone/address information per certificate transmittal selection above:
Request MUST be submitted to the Office of Personnel Management at least two weeks prior to the date needed.
_______________________________________________________
_____________________
Agency/Institution Director/President/Chancellor/Designee Signature
Date
Years of Service/Retirement Certificate Request Form 10/21/2015