Reissue Course Certificate Request

Last Name

First Name

Middle Initial

Suffix (Jr., etc.)

Last 6 digits of your Social Security number

Original course order date and order number

Course name

Your phone number?

Checkboxes

I understand I am responsible for the information entered on this form
I have confirmed the information is correct
I understand there will be a $25 adminitrative fee to have my course certificate re-issued if required due to an error on this form.

ALERT: Please double check you entries BEFORE clicking SUBMIT. A $25 (TWENTY-FIVEY DOLLAR) administrative fee will be charged for re-issuing the course certificate to correct any part of the student’s input that is in error on this intake form. Errors on this form might delay completing the steps required by the State of Texas. Please take the time now to double check your entries above. We cannot overstate how important it is to have the correct information.

Reissue Course Certificate Request

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