P.O. Box 929 Yuma, AZ 85366 Phone: 928-344-7641
ACCUPLACER Distance Request Form
Complete the information below. All fields are required. The estimated processing time is three
business days. Please email or fax this form to testing@azwestern.edu or (928) 344-7712.
Student Information
First Name: Last Name:
AWC Student ID #: Birthdate:
Scheduled test date: Time:
Email:
Phone number:
Type of Test (check all that apply): English Math ESL
Proctor/Test Administration Information
Proctor Name:
Title/Position:
Email:
Name of School/Institution:
School/Institution address:
Phone number: Fax number:
For Office Use Only
Username: _____________________________
Password: ______________________________
Email Sent: ______________________________
PVF Received: ______________________________
PVF Not Received
Reminder Email sent: __________________________
Revised 10/5/16 \\Gryphon\TC$\Website\ACCUPLACER Distance Request Form.docx
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