Appendix 1
Revised 07/2015
(Shaded areas are to be completed by Test
Coordinator or Examiner)
West Virginia TASC Form
AdultEd/Option Pathway
UUID: _________________________
Form: ___________
PLEASE PRINT LEGIBLY
Social Security Number: __ __ __ - __ __ - __ __ __ __
TASC Candidate Last Name: _____________________ First Name:
Date of Birth: __ __ - __ __ - __ __ __ __
Gender: M 
Middle Initial:____________
F  Age:
AdultEd 
Option Pathway 
Email Address: ___________________________________
Phone Number: (___ ___ ___) ___ ___ ___ - ___ ___ ___ ___
Cell Number: (___ ___ ___) ___ ___ ___ - ___ ___ ___ ___
Diploma: Mailing Address or PO Box ___________________________________ City: _________________________
County: _______________________
State: _________________________ Zip Code: _____________________
Signature of Parent/Guardian granting permission for candidate to take the TASC test (if candidate is under 18 years of
age): ______________________________________________________
TASC – To be completed by ABE or Option Teacher (Shaded areas are to be completed by Test Coordinator or Examiner)
Is the candidate named above retesting? Yes  No  The candidate named above will be taking:
Form
Reading 
Writing 
Form
Math

Science 
Form
Social Studies 
UUID (TASC ID)
SCHOOL INFORMATION (To be completed by Principal/Guidance Counselor/Attendance Director) -- Complete this
section for students 16, 17, & 18 years of age Please, place school seal or stamp in this area.
I, ______________________________________________ of _______________________________________________
(Signature of Principal/Guidance Counselor/Attendance Director)
(School/County)
do verify that the candidate named above (check appropriate box):
 Did formally withdraw from an accredited school on this date: _______________________________. Class graduation
date: ___________________________________
 Was enrolled in alternative education beginning on this date: ________________________________ and withdrew
from the accredited school on this date: _____________________________________
 Is enrolled in the Option Pathway. (Sixteen year old enrolled in Option Pathway may take the TASC test.)
 Provided a court order reflecting emancipation or provided a marriage license and is to follow guidelines for 18 yr. old.
(Document must be attached.)
 Began home-schooling on this date: _____________ Home-schooled students must follow state age guidelines for
testing. If home-schooled student is enrolled in classes at a regular accredited school and the school offers Option
Pathway, the home-schooled student may be enrolled as an Option 3 student and permitted to take the TASC test. If the
school does not offer Option Pathway and the home-schooled student is attending classes, fax this form to the State
Administrator at (304) 558-4874 for approval prior to testing.
 The candidate is court ordered and does not need the withdrawal form. (Court order must be attached to this form.)
VOUCHER–AdultEd or Option Teacher completes this section to verify the TASC test candidate’s TRA or OPT scores
The candidate named above is a first-time tester or last tested in the state of _______________ and has scored a
required minimum score on the TASC Readiness Assessment (TRA) as indicated below:
TRA
Math
8 pts 
Reading
9 pts 
Science
7 pts 
Social Studies
9 pts 
Writing
13 pts 
The candidate named above is a retester and has scored a required minimum on the TRA or OPT as indicated below:
TRA
OPT
Math 8 pts 
Math 470 pts 
Reading 9 pts 
Reading 470 pts 
Science 7 pts 
Science 470 pts 
Social Studies 9 pts 
Social Studies 470 pts 
Writing 13 pts 
Writing 470 pts 
Signature of ABE or Option Teacher: __________________________________________________________________
SIGNED RELEASE-The TASC Test Candidate must sign this release section and check all that apply:
 I understand that the local and state Testing Coordinators and Examiners, County Boards of Education, RESAs, accredited schools that I
attended, and workforce agencies with which data sharing agreements exist for the purposes of meeting national performance
measurement standards will automatically have access to my records.
 I affirm that I agree to the terms set forth by CTB/McGraw-Hill™, the West Virginia High School Equivalency Office, and the local
jurisdictions. In case of damaged or lost answer sheets or missing scores, I will be given the option to retest at this center and agree to
limit the liability of all parties concerned to this free testing session.
 I also understand that if I have a disability I may apply for accommodations by contacting the Testing Coordinator for further instructions.
 I understand that no cell phones or other electronic devices are allowed in the testing room.
 I understand that I may not discuss practice test or TASC test items with anyone, including my teacher or family members. I
understand that discussing test items may result in the invalidation of my test.

I would like to participate in the TASC graduation activities and my name may be published with the graduation list.
Signature of TASC Test Candidate: ________________________________________________
Date: ___________________
ATTACH A COPY OF CURRENT & VALID STATE OR FEDERAL ISSUED ID TO THIS FORM
No cell phones are allowed in testing room. State or Federal ID must be presented during each testing session.