The state education department high school

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PLEASE

STAPLE MONEY ORDER O R

CERTIFIED CHECK HERE

ATTACHMENT H

The University of the State of New York THE STATE EDUCATION DEPARTMENT

High School Equivalency (HSE) Office P.O. Box 7348, Albany, New York 122240348

(518) 4745906

REQUEST FOR DUPLICATE COPY OF NEW YORK STATE HIGH SCHOOL EQUIVALENCY DIPLOMA

AND/OR TRANSCRIPT OF GED?/TASCTM TEST SCORES

CFLN:

Please provide the following information to assist us in locating your test records. Your signature is required in the space provided.

IF YOU ARE REQUESTING INFORMATION ON BEHALF OF THE CANDIDATE,

PLEASE BE ADVISED THAT THE CANDIDATE MUST ALSO SIGN THE RELEASE

PLEASE PRINT CLEARLY IN INK

Please check:

Candidate Information:

Last Name at Time of Testing

s Diploma & Transcript ($10.00)

First Name

MI

s Transcript Only ($4.00)

Date of Birth

Month

Day

Year

Social Security Number

Center/Place Where You Tested

Year Tested

Current Address?Street/PO Box

Apt #

City

State

Zip Code

Daytime Weekday Contact Phone Number

(

)

Please Mail Document to:

Name of Institution (If Applicable)

REQUIRED CANDIDATE SIGNATURE (IF APPLICABLE, I GIVE PERMISSION TO THE INDIVIDUAL

BELOW TO OBTAIN INFORMATION ON MY BEHALF.)

Date

SIGNATURE OF PERSON REQUESTING VERIFICATION, IF OTHER THAN THE CANDIDATE, IS ALSO REQUIRED:

Date

Last Name

First Name

Middle Initial

Street

Apartment No.

City

State

Zip Code

Phone Number

(

)

NOTE: A nonrefundable processing fee of $10.00 (diploma with transcript) and $4.00 (transcript only) is required for each document requested. The required fee, made payable to NYSED, must be in the form of a certified check or money order for each request. NO CASH or PERSONAL CHECKS will be accepted. The diploma and/or transcript will not be sent until the required fee is submitted to this office.

Please send your request to the above address.

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