Authorization To Release Official Ged Documents Form 2015

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AUTHORIZATION TO RELEASE OFFICIAL GED

DOCUMENTS

Please type or print the following information. If your application is incomplete, record of your testing will not be

provided. Completed requests should be mailed, faxed or emailed to:

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Arkansas GED

Testing

Three Capitol Mall

Luther S. Hardin Building

FAX: 501-682-1982

Little Rock, AR 72201

EMAIL: GED@Arkansas.gov

PHONE: 501-682-1980

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PART I: AUTHORIZATION TO RELEASE GED

DOCUMENTS DIRECTLY TO THE EXAMINEE.

PLEASE INDICATE THE REQUESTED DOCUMENT:

Transcript

Diploma

Name:______________________________________________________________________________________

(at the time of testing)

Last

Maiden/Other

First

M.I.

Year Tested: ________________________

Location: ______________________________________

(or approximate year)

(city or center name)

Social Security #: _______-_____-________

Date of Birth: ___________________________________

Current Name & Current Mailing Address

Daytime Phone Number

______________________________________________________

(______) _______-___________

______________________________________________________

______________________________________________________

Examinee’s Signature_________________________________________

Date____________________________

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PART II: AUTHORIZATION FOR GED

INFORMATION AND/OR RECORDS TO BE DISCLOSED TO A SCHOOL,

EMPLOYER, MILITARY BRANCH, OR OTHER ORGANIZATION.

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I authorize Arkansas GED

Testing to mail my GED

transcript to the following:

Name of School/Employer/

Military Branch/Organization: _________________________________________________________________

Mailing Address: ___________________________________________________________________________

___________________________________________________________________________

_________________________________________________________________________________

____________________________________________

(Signature of Examinee)

(Date)

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I authorize Arkansas GED

Testing to email my GED

transcript to the following:

ARGED15

JANUARY 2015

Name of School/Employer/

Military Branch/Organization: _________________________________________________________________

Contact Name:

___________________________________________________________________________

____________________________________________________________________

Email Address:

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Program’s right to make an independent determination, at its sole discretion, of whether the information and records identifi ed above are subject

I understand and acknowledge the GED

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Program’s policies for disclosing information. I hereby release the GED

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to disclosure under 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 to any

parties identified above.

ARGED15

Authorization to Release

January 2015