High School Equivalency Release of Information Form

For those who tested in West Virginia Only

Tested Name:

Home Address:

(Where you live now)

Phone Number: () -- --

(Please include a phone number where you can be reached during the day)

YEAR HIGH SCHOOL EQUIVALENCY Diploma/Transcript was ISSUED to you: ______

Your Date of Birth:______

Month DayYear

Social Security Number: ______- __ __ - ______

The name of the center/county where you tested:______

Did you take the GED® or TASC?______

Please sign at the X below to give the WV Department of Education permission to release your

High SchoolEquivalency records.

X

Circle where you want your High School Equivalency Diploma/Transcript mailed scores or faxed (verification only will be faxed)below:

Educational Correctional Institution Military Employer Self

Make money order out and mail all information to following address:

West Virginia Department of Education/High School Equivalency Phone: 3045586315

Capitol Complex, Bldg. 6 Rm. 728 Fax: 3045584874

1900 Kanawha Blvd. E.(verification only)

Charleston, WV 25305

STOP… HAVE YOU INCLUDED everything?

IF you do not send current Photo ID and fee, your request will be returned

If you are requesting a diploma/transcript you must check the first 3 boxes so that we can provide you with the right assistance. If you are a “Re-Tester” please, just check  the 3rd and 4th box.

1.Release of Information Form

2.$10.00 fee is required for each transactions or copy requested

3.Photo copy of Current State ID, Pass Port, or Correctional ID

4.Re-Tester (please check box 1, 3, and 4, no fee is required for retesting)

“When you provide a check as a payment, you authorize us either to use information from your check to make a one-time electronic fund transfer from your account or to process the payment as an image transaction. For inquiries, please call 1-866-243-9010. When we use information from your check to make an electronic fund transfer, funds may be withdrawn from your account as soon as the same day you make your payment and you will not receive your check back from your financial institution.”

Appendix 9

Revised 03/2014