Updated December 2013
Release of Information to
Eastern Wyoming College
Adult Basic Education Program
______________________________ ____/ ___ / ___
Student’s Name (Full legal name) (Date of Birth)
___ ___ ___-___ ___-___ ___ ___ ___
Social Security Number
hereby request and authorize the release the following information concerning myself: (and
copies thereof)
______ Official TABE Test results
______ HSEC Practice Test results
______ Official HSEC Test results
______ Other Record: ________________________________________________
for the purpose of:
______ Employment
______ Continuation of Study Program
______ Other: _______________________________________________________
From/to officials at:
___________________________________________________________________
Academic Institution
___________________________________________________________________
Address
___________________________________________________________________
City State Zip Code
_________________________________ _________________________
Student Signature Date
click to sign
signature
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