Instructions: Please fill in the information below as completely as possible. (*Denotes required fields.)
Please note: As of November 10, 2014, all official GED(R) and HiSET(R) records requests in Iowa must be requested through
Diploma Sender. Requests are completed online at http:/www.diplomasender.com or by calling (855) 313-5799.
(An additional $6.00 charge is added for phone orders.)
*Program of Study:
*Current Address
*City *State *Zip Code
*Location Classes Taken/Diploma Received: (Choose One)
Anamosa State Penitentiary
Belle Plaine
Iowa City Learning Center
Iowa Medical and Classification Center
Cedar Rapids (Lincoln/Resource/Main Campus)
Marion
Monticello
Tipton
Vinton
Washington
Williamsburg
Other--Please Specify
*Item Needed (Choose One)
Official Kirkwood Adult HS Transcript Duplicate Kirkwood Adult HS Diploma ($15 fee required)
I authorize the release of my records to the following individual or agency:
*Name
*Agency/Institution
* Address
*City *State *Zip Code
Phone Number Fax Number
*Signature *Date
For Office Use Only:
Date Received
Date Mailed
Initials
Initials
Kirkwood Community College Adult High School Record Request Form
Return form to: Kirkwood HS Completion Program Attn: Records 6301 Kirkwood Blvd SW
Cedar Rapids, IA 52403 or fax to 319-398-1049. Requests take 5-15 days for processing.
Please Mail Please Fax
Date Emailed
Date Faxed
Adult High School Diploma
*Full Name at time of attendance:
*Current Full Name
*Year Adult High School Diploma Received
*Phone Number
*Social Security
Number
*Date of Birth:
Month Day Year
