Request for a Certificate of Appreciation
From Department of Public Instruction – School Nutrition Team For Retiring Child Nutrition Programs Employee
Do you know a school nutrition employee retiring this year? The Department of Public Instruction – School Nutrition Team would like to recognize him/her for their many years of dedication and commitment to the health and nutritional well-being of the students they serve. Please complete and submit this form for a certificate of appreciation.
Name of Retiree
Print name clearly and exactly as it is requested on certificate. Include credentials, if applicable, and requested on certificate.
Total Years of Service
In Child Nutrition Programs
School District(s)
List current school district and any others the retiree may have worked in.
Date to be Printed on Certificate
This date is the Retirement date or Date certificate will be presented to retiree
Name of Person Requesting Certificate Send Certificate to Address
Fax completed request form to
Trish Briscoe, Operations Admin Assistant DPI – School Nutrition Team Fax #: 608-267-0363