Assessment Center
De Anza College Assessment Center 21250 Stevens Creek Blvd. Cupertino, CA 95014
Room: RSS143 / Phone: (408) 864-8717 / Email:
Per your request to take an Accuplacer placement test at a remote location, please submit this completed form
to the De Anza College Assessment Center at It is the student’s responsibility to
confirm a proctor. Upon receipt of this completed form, the Assessment Center will contact your proctor
directly. This process can take up to five (5) business days.
Student Name:
De Anza Student ID#
1) Determine if you are eligible for placement test: and
become familiar with the study guides
2) Indicate Your Requested Accuplacer Placement Test(s):
English & Math English only Math only
At this time, De Anza does not have the capability to provide for remote ESL Placement Test.
2) Indicate the institution or testing center that will proctor your placement test(s).
A proctor CANNOT be a family member, relative, or friend. Eligible proctors include: counselors, teachers,
librarians, or proctors from another institution. If you have a question about the eligibility of a proctor, please
contact the De Anza Assessment Center.
Institution: ________________________________________________ Testing Date: ____________
Proctor Name: _________________________________________ Title: ______________________
*Email: ______________________________________________ Phone: ______________________
*Must be a valid academic email address. Emails cannot be sent out to Gmail, Hotmail, MSN, Yahoo, or other general accounts.
Student Signature: _____________________________________________ Date: _____________
By signing above, I grant De Anza College permission to contact the above proctor on my behalf to
coordinate a remote placement test(s). I understand that this can take up to five (5) business days.
FOR OFFICE USE ONLY Do not complete
1) Date Received:
3) Date Proctor Packet Sent:
4) Proctor Username & Password Sent:
Yes / No
2) Date Proctor Confirmed:
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