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Request a Certificate

To request a certificate, please fill out the following form. Items marked with an asterisk (*) are required information. 

if you have any questions while completing this form please contact


Veronica Aguilar

TEL: (213) 241-4657

Date of Request* 

Name of Person Requesting *

Full name of (Organization/Employee/Staff/Teacher/Student) that is being recognized: *

Description of what individual/organization is being recognized for: *

***Certificate of Retirement Only

Employee Number

Total years of service with LAUSD:

Current Title of Employee

Last Place of Employment:

Programs Participated In:

Special Awards/Recognitions:

Date Certificate Needed By: *

Person Picking Up Certificate : 




Location where certificate will be picked up*

Beaudry LAUSD Headquarters

Additional Comments:

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