Records Release - Candidate

Records Release - Candidate

PLEASE NOTE: Please allow 5-7 business days for processing and verification of student records.
Exam Candidate Information:
Name*

First NameMiddle InitialLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Phone Number*
Please enter a valid phone number.
Home Phone Number*
Please enter a valid phone number.
Authorization Checkbox
Candidate Email Address*
example@example.com
Third Party Release
Recipient Email*
example@example.com
Click here to read the Records Policy.
Check the box below to confirm you have read and understand the Records Policy.*

I have read and understand the Records Policy.
Check the service(s) you are requesting:

Contractor Examination (This will provide the title, date of the examination(s), and Pass/Fail status; this will NOT provide an examination score.)Certification Examination (Thiswill provide the title, date of the examination(s), and Pass/Fail status; thiswill not provide an examination score.)Certification History (This will provide the Certification title and time period during which an individual held certification(s))
Payment Authorization:

Total Amount: $30.00

For your security, ICC Credentialing elects to collect credit card information via telephone. If paying by credit card, please provide name on credit card and authorize the purchase.
Name as it appears on credit card*
I authorize ICC Credentialing to contact me to collect my credit card information via telephone.
If paying by check, please contact us at acrequests@iccsafe.org and we will email you the paper form.
I hereby certify that I am the person indicated above, that all the information I have given herein is true and complete to the best of my knowledge, and that any false statement will be cause for voiding this application.
PLEASE NOTE: Please allow 5-7 business days for processing and verification of student records.
Should be Empty: