Credential Release and Waiver Form
Authorize the release of your credentials and acknowledge the waiver terms for disclosure.
Full Name of Credential Holder
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Current Organization or Institution
*
Type of Credential to be Released
*
Please Select
Academic Transcript
Professional Certification
Diploma
Other
Credential Reference Number (last 4 digits only, if applicable)
Recipient Name or Organization
*
Recipient Email Address
*
example@example.com
Reason for Release
*
Relationship to Credential Holder (if not self)
Date of Credential Release
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature of Credential Holder
*
Submit Authorization
Submit Authorization
Should be Empty: