Note: Applicant is to complete this form and send it to their school or instructor (do
not return to ARCB) for release of the educational records.
To:
Instructor name:
School Name:
Street address1
Street address 2
City
State
Zip code
From:
Your Name
Street address1
Street address 2
City
State
Zip code
As a previous student of yours, you are hereby authorized and requested to send a copy
of my educational records to the American Refloxolgy Certification Board as part of
my testing application. Please send them to: ARCB, PO BOX 5147, Gulfport, FL 33737.
Telephone: 303-933-6921. Or you may fax them to 303-904-0460.
Thank you for your prompt attention in this matter
