DPS Learner Record Access Request Form
Use this form to request access to your own learner records.DPS may verify your identity before providing records.
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Learning Event Information
Course / Program / Learning Event
Date Attended
-
Month
-
Day
Year
Date
Request Type
*
Copy of my certificate
Copy of my completion record
Access to mu learner records
Correction of incorrect learner information
Other
Record Requested
Please state the record or information you are requesting
Please confirm one detail DPS can use to verify your identity [Example: email used during registration, course title, or completion date]
Correction Request
Only if requesting a correction [What information needs to be corrected? What is the correct information?]
Authorization
I confirm that the information in this form is correct.
I understand DPS may verify my identity before providing records.
I authorize DPS to process this request.
Signature
Date Submitted:
-
Month
-
Day
Year
Date
Contact Note
If you have questions about this request, please contact DPS at dynamicsystems25@gmail.com
Submit
Should be Empty: