Release of Candidate Examination Information to Governing Jurisdictions
PLEASE NOTE: Requests may take 7-14 business days for processing and verification of student records.
Agency Information:
Name of Agency
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
ATTN
*
Testing Score
*
Required Score
Candidate Information:
Name of Candidate
*
First Name
Last Name
Name of Examination
*
Candidate ID Number
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
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.
Electronic Signature - Please Check Box to Confirm
*
I hereby certify that I am the person indicated above, that all the information I have given herein is true and compete to the best of my knowledge, and that any false statement will be cause for voiding this application. I give permission for ICC to release the exam results to the agency specified on this form.
Submit
Should be Empty: