PDF Authorization to Release Official Ged Documents
[Pages:1]AUTHORIZATION TO RELEASE OFFICIAL GED DOCUMENTS
PLEASE TYPE OR PRINT THE FOLLOWING INFORMATION. IF YOUR APPLICATION IS INCOMPLETE,
RECORDS OF YOUR TESTING WILL NOT BE PROVIDED. COMPLETED REQUEST SHOULD BE
MAILED OR FAXED TO:
Arkansas GED Testing
#3 Capitol Mall
Luther S. Hardin Building
Little Rock, AR 72201
FAX 501-682-1982
PART I: AUTHORIZATION TO RELEASE GED DOCUMENTS DIRECTLY TO THE EXAMINEE
PLEASE INDICATE THE REQUIRED DOCUMENTS BELOW.
Transcript
Diploma
Retest Application
NAME: _______________________________________________________________________________
(At the time of testing) Last
Maiden/Other
First
M.I.
YEAR TESTED: ______________ (or approximate year)
LOCATION: _______________________________________
SOCIAL SECURITY #: _____________________________ DATE OF BIRTH: ___________________
CURRENT NAME & CURRENT MAILING ADDRESS:
__________________________________________
__________________________________________
__________________________________________
__________________________________________ DAYTIME PHONE NUMBER:____________________________________________________________________
_____________________________________________________________ (Signature of Test-Taker)
_____________________ (Date)
PART II: THIRD PARTY RELEASE PLEASE CONTINUE IF YOU ARE REQUESTING THAT DOCUMENTS, INFORMATION, AND/OR RECORDS BE DISCLOSED TO A THIRD PARTY.
I hereby authorize Arkansas GED Testing to provide copies of the indicated documents to the following Third Party:
Transcript
Diploma
Retest Application
Third Party Name:
________________________________________________________________
At the following address: ________________________________________________________________
________________________________________________________________
I understand and acknowledge the GED Program's right to make an independent determination, at its sole discretion, of whether the information and records identified above are subject to disclosure under the GED Program's policies for disclosing information to third parties. I hereby release the GED Program, its employees, its attorneys, its governing bodies and its agents from any and all liability and claims of every kind and character that are based upon or relate in any way to the disclosure of information in accordance with this authorization to any actions of the third party identified above.
_____________________________________________________________ (Signature of Test-Taker)
_____________________ (Date)
ARGED15 April 10, 2002
................
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