Chspe Certificate/transcript Order Form
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CHSPE
CERTIFICATE/TRANSCRIPT ORDER FORM
Please PRINT carefully or type all information requested below.
California High School
For information, call 866-342-4773.
Proficiency Examination
PERSONAL INFORMATION
Last Name (Please specify the name used at the time of testing.)
First Name
Middle Initial
Date of Birth
Approximate Test Date
CHSPE ID # (if known)
PERSONAL CONTACT INFORMATION
Name — only if your name has changed
Mailing Address
City
State
ZIP Code
Daytime Phone Number
Evening Phone Number
E-mail (if available)
______ - _________ - _________
______ - _________ - _________
ORDERS
FEE PER UNIT
X
QTY
=
TOTAL FEES
DUPLICATE CERTIFICATE(S) – The $25 fee is charged for EACH duplicate certificate ordered.
$25.00
X
=
$
TRANSCRIPT(S) – The $15 fee is charged for EACH transcript ordered.
$15.00
X
=
$
Note: Certificates and transcripts will be mailed via first-class mail within ten business days of receipt of this order form. If you request and pay for Rush
Service, your materials will be mailed via overnight service within three business days of receipt of this order form.
RUSH SERVICE – $15 per mailing address. Rush Service is not available to post office boxes,
$15.00
X
=
$
military post office boxes, or locations outside of the continental United States.
per address
RELEASE INFORMATION
TOTAL FEES FOR THIS ORDER
$
I certify that I am the person whose name and signature appear on this form. I authorize release of my
certificate/transcript to me and/or the recipients designated below.
Signature (required) (If under 18 years old, a parent/guardian must sign.)
Date
SEND DOCUMENT(S) TO:
(For each shipping address requiring Rush Service, please check Rush Service box(es) below. Use an
additional piece of paper if you are ordering documents to be sent to more than two addresses. Check the “Fax a copy” box if you would like a
copy faxed to the same recipient prior to shipment of your official document.)
Shipping Address:
Shipping Address:
Certificate
Transcript
Rush Service
Certificate
Transcript
Rush Service
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Name of Organization
Name of Organization
Attn:
Attn:
Address
Address
City
State
ZIP Code
City
State
ZIP Code
Phone Number
Phone Number
FAX a copy / FAX Number
FAX a copy / FAX Number
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MAILING INFORMATION
HOW TO PAY YOUR FEES:
If using U.S. Postal Service, mail this
If using another delivery service, such as
Enclose a money order or bank-issued
completed form and proper payment to:
FedEx, UPS, etc., mail this completed form and
cashier’s check payable to the California
proper payment to:
Department of Education. Incomplete forms
CHSPE Office
CHSPE Office
and forms received without proper fees will
Sacramento County Office of Education
Sacramento County Office of Education
Attn: CHSPE Records Request
Attn: CHSPE Records Request
be returned to the requester. Cash, personal
P.O. Box 269003
10150 Missile Way
checks, and payments using credit or debit
Sacramento, CA 95826-9003
Mather, CA 95655
cards will not be accepted.
866-342-4773
916-228-2665 (Fax)
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