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For CLEP and DSST

MILITARY TRANSCRIPT ORDER FORM scores on tests taken


preasewpE.,.lTlof."i:llf after Juty 1,1974
1.:llXo'*uestedberow.
There is no charge for transcripts sent to Offcers OCO'S). DANTES TCO transcripts are and are to
used for counseling purpo$es only. Mail completetl form to: Prometric, ATTN: DSST/CLEP Transcripts, 1260 Energy Lane, St. Paul, MN 55108
Toll Free (877) 471-9860 Phone (651) 603-3012 Fax (651)603-3008 OR email completed ecanned form to: PNJ-DANTES@prometric.com.

PaymenUFee Information
A $30 fee is charged for each transcript ordered. A transcript may include any or all DSST and CLEP scores taken while in the military
NOTE: Transoipts are mailed within three weeks afror receipt of the order form at Prometric.
Transcript Orders Ulit P{cq X QTY = , Total Fee
DANTES Test Control Omcer (OaHreS TCO), OaltfES TCO lD#: No charge $0
(DANTES TCO's are sent unofficid transcripts for counseling purposes
only. For)rour DANTES TCO to re€ive an unofficialtranscript, you I I
MUST provide the DANTES TCO lD Number in tne shaded box.) | |

To be sent to Personal Home Address (lisied under "Peronal lnformation" bdow) $30 $
To be sent to School(s) (comdete school addrcss in box(€s) below) $30 {per school) / $ So va +e5lr..-*tti^r
Order Total $ 55, Ai,
Paymen* Fee(r) may be paid by MaslerCard, Visa or American Eryress, certified check or money order, payable to Prometric. Incomplete forms or
foms received without the conect fees will be Rtumed. Personal checks and cash are not accepted. Fees are nonrefundable.
To pay for your transcript with Master0ard, Visa or American Express, please supply the information below:
creoit ffi vrsa l-l nc l-l euex
card: l4J i_l LJ
Credit Card Numbe[

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Personal Information (please TYPE or Print all information requested below):
Last Name (include Maiden Name or Former Last Names, if applicable) First Name Middle Initial Social Security Number
.bor><-Ey ADA"n C €s{-4o -56tJ
Street Address (induding Apt. number or P.O. Box, if applicaue) Date of Birth (MIVVDD/YYYY)
q?s/ Partt, Aepae SI | |
City ./ ZIP Code
FRAv.f
Numhr (irduding area code)
Fr- se747
Phone EmallAddress
(1V7)5i3*155i o-J,uon 16
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Transcript Information
Please prepare my transcript and include the following (Check only one)
ff Scoree on ail tests fl O*y lest scores that are at or above the ACE Recornmended Minirnum Score
E Only scores on test titles listed below:
restiltlei CpLit6"(. At1'tp*A (11or,1, t{v*ns1165(o4c,-:), (orrnii/it-rr#.si,$HtrToa/ (oi,r.ui)
(MMlDDffYYn: O 2*/ tl / Zoog
Approximale Date of Last DSST or CLEP Test

Permission for release of records (transcripts will not be issued without signature)

Gandidate's Signature: z.z-z


I hereby authorize Prometric to release my transcript(s) to the address(es) below.

Address(es) where transcript{s) should be sent


Date: 7./;"&,/tX*tX,

fl Personal f{om6 Address (as listed above) and/or

SchoolName: schoo}Name
Urv,v€t>tly o{: Noet r FLr,u0A
Attn: Out, Srdr Stvae."i Sanvrcas Attn:

Address:
I uilF Dr.tvt Address:

City & State: 5A6KS. ,t_ye, fU Zi0Gcd,e3777, city& state Zip Code:
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Copyright @ 2010 Prometric lloldings LLC (Prometric), a Dela{Ere limited liability company
Rev 20100322 PROM ETR IC

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