Permission to Transfer/Share BHP Blended Curriculum Transcript

BHP Permission to Share/Transfer Blended Curriculum Transcript

Name(Required)

First Last

Email(Required)

Last 4 of SSN #:(Required)

Birthdate (mm/dd/yyyy)(Required)

Please read the following section very carefully.(Required)

Please select either Option A or Option B, and complete all of the questions that follow thoroughly. To ensure that your request is processed in a timely manner, please fill out this form accurately, and contact your supervisor if assistance is needed.

Option A: I am currently employed with only one agency/school, and want to transfer my BHP training transcript to that ONE organization.

Option B: I am currently employed with MORE THAN ONE agency/school, and want to transfer my BHP training transcript to multiple organizations.

Name of Agency/School(Required)

Date of Hire(Required)

Name of Agency/School 1:(Required)

Name of Agency/School 2:(Required)

Name of Agency/School 3:(Required)

If you only have 2 agencies/schools please put N/A

Signature/Consent(Required)

Please type your full name to signify your permission to share this transcript with the listed parties.