Fillable Delta College TESTING SERVICES REQUEST FORM 2017

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Delta College TESTING SERVICES REQUEST FORM 2017

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File type: PDF

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DELTA COLLEGE TESTING SERVICES REQUEST FORM
Testing Center, A133 ♦ 1961 Delta Road ♦University Center, MI 48710
Phone: 989-686-9182 ♦ Fax: 989-667-2213 ♦
e-mail: testingcenter@delta.edu
EXAMINEE INFORMATION
Name
Street Address
City, State, Zip
Telephone
e-mail
Appointment Date & Time: 1
st
Choice
Appointment Date & Time: 2
nd
Choice
EXAM INFORMATION
Exam Name/Course Title
Type
CLEP DANTES/DSST PROCTOR
PROCTORED TESTS ONLY
College/University
Instructor/Contact
Phone Number
e-mail/Fax Number
Time Allowed
Format
Paper/Pencil Computer
DO NOT WRITE IN THIS SECTION – FOR OFFICE USE ONLY
Exam Date
Exam Time
Start:
Proctor Signature / Date
Confirmation Notice:
Appt. Calendar:
Stats:
ATC Receipt#:
DELTA COLLEGE ADMINISTRATION FEE - $35
Cashier – Deposit into Testing Fees
Discover Card / MasterCard / VISA
Receipt #
Amount Paid
Expiration -
3 Digit Code -
Date Paid
Received by
Cardholder Name -
Billing Address -
Revised: January 2017
L:\Projects\LLIC\Testing Center\forms\Testing Center Services Request Form.pdf
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Delta College TESTING SERVICES REQUEST FORM 2017

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Completed 7 February 2020

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