
C
C
O
O
O
O
K
K
C
C
O
O
U
U
N
N
T
T
Y
Y
G
G
E
E
D
D
®
®
T
T
E
E
S
S
T
T
I
I
N
N
G
G
P
P
R
R
O
O
G
G
R
R
A
A
M
M
REQUEST FORM FOR
GED CERTIFICATE & OFFICIAL TRANSCRIPT OF GED TESTS RESULTS
Instructions – Read Carefully
Use this form to request a GED Certificate or Official Transcript of GED Tests Results, only if you tested in Cook
County, Illinois. You may be eligible to receive a Certificate and/or Official Transcript of GED Tests Results free of
charge. DO NOT FILL OUT THIS FORM FOR A FREE CERTIFICATE OR TRANSCRIPT, please contact our office at
(847) 328-9795 and press ‘0’ to speak to a Customer Service Representative. To request additional certificates or
transcripts complete this form and submit it with a money order or cashier’s check payable to ICCB-GED in the correct
amount ($3.00 for each transcript and $10.00 for each certificate) to the address above. Please allow 2-3 weeks for
delivery. Fees paid are NON-REFUNDABLE. If you are ordering a transcript and a certificate, the certificate will be sent
separately. Please PRINT or TYPE.
Mark the number of each item you are requesting.
[____] Official Transcript: ($3.00 each) Today's Date: _________/________/________
[____] Certificate ($10.00 each) Total Amount Enclosed: $_____________
(If you paid a $35 or $50 application fee, your certificate will (Money order and cashier’s checks must be made payable to
be sent to you at no additional charge. DO NOT send this ICCB-GED. No personal checks, cash, or credit cards will be
form in unless you are requesting additional certificates.) accepted. Fees are non-refundable and non-transferable)
P
P
E
E
R
R
S
S
O
O
N
N
A
A
L
L
I
I
N
N
F
F
O
O
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M
M
A
A
T
T
I
I
O
O
N
N
Name Used at Time of Test: _______________________________________________________________________
(Note: Proof of name change will be required) First Name Middle Name or Initial Last Name
Current Name: _______________________________________________________________________
(If different from the name used at time of testing) First Name Middle Name or Initial Last Name
Social Security Number or ID #:_____________________________ Date of Birth: _________/________/_________
Current Address:________________________________________________________ Apartment #:_______________
City:____________________________ State:________ Zip:___________ Phone Number:(____)_________________
Date of Test: (approximately) _________/________/_________ Test Center: _____________________________________
Print your name on the line below exactly the way you want it to appear on your GED Certificate.
* (If name differs from name on file, proof will be required. See the back of this form for more information)
__________________________________ ____________________ __________________________________
First Name Middle Name or Initial Last Name
T
T
R
R
A
A
N
N
S
S
C
C
R
R
I
I
P
P
T
T
R
R
E
E
C
C
I
I
P
P
I
I
E
E
N
N
T
T
I
I
N
N
F
F
O
O
R
R
M
M
A
A
T
T
I
I
O
O
N
N
Complete this section ONLY if this transcript is not being sent to you. (Colleges, Employers, Institutions etc.)
Name of College:__________________________________________ Attention: Office of Admissions and Records
Address:___________________________________ City:___________________ State:______ Zip Code:___________
Name of Institution/Employer: ______________________________ Attention:_______________________________
Address:___________________________________ City:____________________ State:______ Zip Code:___________
My signature below shows that I authorize my GED scores to be released the above institution.
Signature _____________________________________________________ Date__________________
Please Keep a Photocopy for your Records!
Mail Request To: ICCB-GED
P.O. Box 88725 Chicago, IL 60680-1725
Phone: (847) 328-9795