Fill out a separate form for each plaque requested. Allow two weeks for delivery. If you have any questions, please call Rudy Bartolo, Retirement Plaque Coordinator at ext. 5558. FORM MUST BE SUBMITTED (mailed or faxed) in order for work to commence. Return form to Retirement Plaque Coordinator, Mailstop 77R0125, or fax 4993.

Requester’s Name:_______________________________ Extension:_______________

Mail Stop: ________________ Today’s date:__________________

With Frame _____ Without Frame_____ Date Needed: ________________________

Full name as it is to appear on plaque:_________________________________________

Number of years employed at Lab:______________

Beginning and ending dates of employment: ____________________________________

Choose a format: Space below for custom message (Actual Size 5" x 3")

#1_____ Beginning & Ending Years
#2_____ Ending Year
#3_____ Beginning & Ending Dates
#4_____ Custom Message (Fill in Below - please type)