Fillable Delta College TESTING SERVICES REQUEST FORM 2018

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Delta College TESTING SERVICES REQUEST FORM 2018

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DELTA COLLEGE TESTING CENTER
1961 Delta Road, A133
University Center, MI 48710
Phone: (989) 686-9182
Fax: (989) 667-2213
TESTING SERVICES REQUEST FORM
EXAMINEE INFORMATION
Name:
Street Address:
Telephone:
E-mail:
Appointment Date & Time: 1
st
choice:
Appointment Date & Time: 2
nd
choice:
EXAM INFORMATION
Exam Name/Course Title:
Type (please pick one): ☐ CLEP ☐ Dantes/DSST ☐ Proctor
INSTITUTION INFORMATION (Proctor Only)
College/University/Other Institution Name:
Instructor/Contact:
Phone Number:
E-mail:
Time Allowed:
Format (please pick one): ☐ Paper/Pencil ☐ Computer
OFFICE USE ONLY – DO NOT WRITE
Exam date:
Exam Time:
Proctor Signature & Date:
DELTA COLLEGE ADMINISTRATION FEE: $35 PER TEST
Cashier – Deposit into
Testing Fees
Discover/MasterCard/Visa
(American Express not accepted)
Receipt #
Number:
Amount
Expiration: CVV:
Date
Cardholder Name:
Received by
Billing Address:
L:\PROJECTS\LLIC\Testing Center\Forms\Services Request form 2018.docx
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Delta College TESTING SERVICES REQUEST FORM 2018

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Completed 7 February 2020

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