Request a Retirement Certificate from Fire Marshal

2. Creating an account or logging in to Form Center is optional and is not required to submit this form.

4. Certificate is for:
6. Rank at Retirement
7. First Name
8. Last Name
10. Fire Department
12. Date of Retirement
13. Total Years of Service as a Firefighter
15. If total years are combined from additional departments, list here:
17. Requestor Information:
19. Name
20. Email Address
22. Address (certificate will be mailed to this address)
24. City
25. State
26. Zip Code
28. Phone Number
30. Additional Information
32. Contact Jill Bronaugh, Public Information Officer, if you have any questions regarding the requested certificate

    jill.bronaugh@ks.gov   (785) 296-3403

34. **We will only recognize individuals whose retirement date falls within the current Fire Marshal’s tenure of 2012 to present.
36. ***Please allow two weeks to receive certificate.
Leave This Blank:


38. 1. Receive an email copy of this form.
39. Email address

    This field is not part of the form submission.

40. Submit

* indicates a required field