* Required

Name

Previously used name(s)

Last four digits of SSN

Phone number

Personal email

Years of service

(ex. 1997-2005)

Position held

Please select item(s) needed

Districts are required to provide the record no later than the 30th day after the request is made or the 30th day after the date of the last day of the individual’s employment, whichever is later.

Official service records Transcripts

For service records, please indicate your resignation date

Please indicate how you would like to receive the document(s)

(Signature and photo ID will be required for pick-up.)

Mail to the following address I will pick up my request in person. Please call when ready. Email to the address below

Please provide the name and email address of who the employee record should be sent.

Your Name or Name of School District

Email Address

Address

Your name or school district name

Street address

City

State

Zip code

Signature

Employee signature

Date (mm/dd/yyyy)

Please send a confirmation email to the address below: