Form Nde 12-003 - Application For Nebraska Ged Testing
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1NDE 12-003
Revised: 4/2014
APPLICATION FOR NEBRASKA GED
TESTING
®
This form must be completed by 16/17-year olds before any official GED
testing may begin.
®
Type or print neatly in BLACK ink
Last Name
First Name
Middle Name
Social Security Number
E-Mail Address
Date of Birth-Verification Attached*
___ ___ ___ - ___ ___ - ___ ___ ___ ___
____ ____ / ___ ___ / ___ ___ ___ ___
Current Address
Number and Street or PO Box
City
State
Zip
Alternate Address
Number and Street or PO Box
City
State
Zip
Home Phone Number
Cell Phone Number
Emergency Phone Number
Residency
Have you been a Nebraska resident
(
)
(
)
(
)
for at least 30 days? Yes No
Official High School Withdrawal Date
Last School Attended
Or Home School Completion Date
Name of School
City
State
____ ____ / ___ ___ / ___ ___ ___ ___
OR
Official transcript attached
Signed homeschool transcript attached
Signed Form 10-005
(Nebraska Withdrawal from Mandatory Attendance) has been submitted to the Nebraska Department of Education and is attached.
OR
Signed copy of Form C (Acknowledgement Letter from NDE to Discontinue Enrollment) is attached.
OR
Signed copy of Form D (Acknowledgement Letter from NDE - Completion) is attached.
I certify the above statements are true to the best of my knowledge: ____________________________________
_____________________
(Examinee Signature)
(Date)
*Date of Birth Verification
FOR STATE DEPARTMENT USE ONLY
Examinee:
Test
Date
S.S.
% Rank
Provide copy of Official Transcript from last
high school attended with date of birth
Reasoning Through Language Arts
or
shown
provide a copy of one of the
items shown below:
Mathematical Reasoning
Baptismal Certificate
Science
Birth Certificate
DD21 Discharge Form
Social Studies
Draft Card
Driver’s License/State ID
Format:
145 Minimum & 580 Total
Pass
English Spanish
TOTAL SCORE
High School Transcript
Military ID Card
Fail
Photo Bearing Passport
Test Center:
Mail to:
Examiner Signature:___________________________________
Adult Education
Nebraska Department of Education
PO Box 94987
Diploma issued by LEA ____ Date: ____/____/____ Date Reported to NDE: ____/____/____
Lincoln, NE 68509
Diploma issued NDE ____
Date: _____/_____/_____ Diploma #: _________________ Receipt #: ______________________
Duplicate Diploma issued NDE ____ Date: _____/_____/_____ Diploma #: _________________ Receipt #: ______________________
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