HIGH SCHOOL DIPLOMA / GED SELF-ATTESTATION FORM

HIGH SCHOOL DIPLOMA / GED SELF-ATTESTATION FORM

FORM ELT HSD-ALT - REVISED 6/2023 - This form is to be used when all methods of obtaining High School Diploma or GED credential verification have been exhausted.
I HEREBY CERTIFY UNDER PENALTY OF PERJURY, THAT THE FOLLOWING INFORMATION IS TRUE:
I have completed a:*

High School DiplomaGED
Name of High School or Educational Organization
High School Diploma Date obtained (Month and Year)

MonthDayYear
Date
City and State of High School
GED completed at (Name of School or Educational Organization)
City and State of GED
GED Date obtained (Month and Year)

MonthDayYear
Date
I have exhausted all outlets of obtaining verification of my high school diploma or GED attainment.

Yes
I ATTEST THAT THE INFORMATION STATED ABOVE IS TRUE AND ACCURATE, AND UNDERSTAND THAT THE ABOVE INFORMATION, IF MISREPRESENTED OR INCOMPLETE, MAY BE GROUNDS FOR IMMEDIATE TERMINATION OF THE ELTU PROGRAM & CERTIFICATE AND/OR I MAY BE BOUND TO AND HELD BY PENALTIES AS SPECIFIED BY LAW.
Name*

First NameLast Name
Student Email*
example@example.com
APPLICANT'S DATE SIGNED*

MonthDayYear
Date
STUDENT SIGNATURE *

Clear
STUDENT'S FULL MAILING ADDRESS*
STUDENT'S PHONE*
Should be Empty: