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NYS Transcript Request

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4 views

NYS Transcript Request

Uploaded by

Ruby
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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APPLICATION H

CERTIFIED CHECK HERE


STAPLE MONEY ORDER
Request for a copy of a NYS
The University of the State of New York
High School Equivalency
PLEASE THE STATE EDUCATION DEPARTMENT
High School Equivalency (HSE) Office diploma or transcript.
89 Washington Avenue, EBA 460, Albany, New York 12234
(518) 474-5906

Do NOT use this form to obtain high school transcripts or other school
OR
records. Contact the high school that you attended.
Please provide the following information to assist us in locating your records.
IF YOU ARE REQUESTING INFORMATION ON BEHALF OF THE DOCUMENT HOLDER,
PLEASE BE ADVISED THAT THE DOCUMENT HOLDER MUST ALSO SIGN THE RELEASE.

CFLN: Do NOT send cash or personal checks.


(For Office Use Only) ONLY money orders or certified checks will be accepted.
Check One: Diploma & Transcript ($10.00) Transcript Only ($4.00)

Document Holder Information: Please type or print clearly in ink.


Last Name at Time of Completion First Name Middle Initial Suffix Date of Birth
/ /
mm dd yyyy
Social Security HSE Pathway Institution Name Year Credential Earned
Number (Last 5­ (choose one)
Digits) or
Other Government ID GED®/TASC™ Test Center Name:

24-College Credit College:

Email Address:
NEDP Program NEDP Agency:

Current Home Address–Street/PO Box and Apt. Number Apt # Daytime Phone Number
( ) -
City State Zip Code

Phone Email
( ) -

Mail the Diploma and/or Transcript to (if other than to the address indicated above):
Recipient Name (Person, college, employer, etc.)

Street Apartment No.

City State Zip Code Phone ( ) -

Phone Email
( ) -
NOTE: A non-refundable processing fee of $10.00 (diploma with transcript) or $4.00 (transcript only or failure notice) is required for each
document requested. The required fee, made payable to NYSED, must be in the form of a MONEY ORDER or a Certified Check for each request.
NO CASH or PERSONAL CHECKS will be accepted. For international document requests, a pre-paid, self-addressed return envelope that is at
least 6 by 9 inches must be included with this form. International money orders must be drawn on a U. S. bank. The diploma and/or transcript will
not be sent until the required fee is submitted to this office. Mail your request to the address indicated on the top of this form.
Document Holder’s Signature

X_____________________________________________________________________________ Date __________________________


Signature mm / dd / yyyy
Note: If you are not the document holder and are obtaining a diploma/transcript for another at the NYSED HSE Window, you
must have a notarized letter stating that you are authorized to obtain the record.
Required Signature of Person Requesting Verification (If other than the document holder)

X_____________________________________________________________________________ Date __________________________


Signature mm / dd / yyyy
8.25.17

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