Release of Information

Release of Information
INSTRUCTIONS

Please fill out the form below.

We will begin to process your request once we receive the following:
- notification of payment
- a completed "Release of Information"
- a copy of your valid driver's license
At this time we are not offering the "pick-up" option. Your documents will be mailed to you at the address you provide in your application/form.

**INFORMATION PROVIDED IN THIS FORM WILL BE HANDLED CONFIDENTIALLY IN COMPLIANCE WITH ALL APPLICABLE FEDERAL LAWS.**
Student Name*

First NameLast Name
Student Maiden Name (if applicable)

First NameLast Name
Email Address*
example@example.com
Phone Number*

Area CodePhone Number
Delivery Address (Please note that it is your responsibility to provide an accurate and current mailing address so that your documents can be delivered to you.)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I hereby authorize Milpitas Adult Education to release the(se) document(s) requested by me.*

Official Transcript ($5)Student Verification ($5)Student Attendance Records ($5)
Upload a clear copy of (image or PDF) of your valid driver's license.*

Browse Files

Cancelof
Do you have any additional information or instructions?
ELECTRONIC SIGNATURE:

By typing my name below, I authorize Milpitas Adult Education to release the information requested via this form. I understand the nature of this release.
Print Full Name*

Order Documents*

Official Transcript$5.00

Quantity

Student Verification$5.00

Quantity

Student Attendance Report$5.00

Quantity

Total $0.00