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