CLEP Reserve a Date Form
Contact Information (Please print all information clearly)
Name First_______________________________ Last ________________________________
Address ______________________________________________________________________
City _____________________________ State ___________ Zip Code _______________
Phone Home ______________________________ Cell _______________________________
Testing Accommodations
If you require testing accommodations due to a learning, physical, psychological, hearing, visual
and/or medical disability and need special assistance or accommodations, please contact our
office well in advance at (845) 574-4288/4525. All accommodations must be approved and
arranged prior to taking the CLEP test.
Is Rockland Community College receiving your results? ____Yes _____No
Are you a DANTES-funded military examinee? ____Yes _____No
Exam Information (Indicate below the CLEP exam title you plan to take)
Note: If taking an exam with essay please indicate “essay required”
CLEP exam title: __________________________________________________________
Test Date and Time
Please enter below your first choice and an alternate date for testing.
First Test Date ___________________________ Second Test Date ___________________
You will receive confirmation of your test date and time by mail.
Payment Information
Test Administrative fee: A nonrefundable $25 money order only (payable to RCC Association).
Return the completed form and fee to: Rockland Community College, Placement and
Assessment, Technology Center Room 8340, 145 College Rd., Suffern NY 10901.
