Fillable Form 79416: AUTHORIZATION TO RELEASE TEST SCORES FORM (South Plains College)

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Form 79416: AUTHORIZATION TO RELEASE TEST SCORES FORM (South Plains College)

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AUTHORIZATION TO RELEASE TEST SCORES FORM
Levelland Campus Reese
Center
Testing Office Testing
Office
1401 S. College Avenue 819 Gilbert
Drive
Levelland, TX 79336 Lubbock, TX
79416
Phone: 806.716.2367, 806.716.2530 Phone: 806.716.4631,
806.716.4689
barant@southplainscollege.edu jtrusty@southplainscollege.edu
NOTE: Send form via email to the corresponding campus the student took the
test
If student tested at the Plainview Campus, or Byron Martin Center, please send it via email to the Reese Testing
Office.
General Personal Information
Last Name First Name Date of Birth (MM/DD/YYYY)
_
Telephone Number ***SPC Student ID #
*Test Date(s) (MM/DD/YYYY) Campus Location Tested
Release Statement
I, , hereby authorize South Plains College, Testing
Full Name (Please Print)
Center, to send my test scores to .
(Name of Institution)
Institution Information
Name of Administrator Telephone # of Institution Fax or email of Institution
_
Address of
Institution
Student’s Signature Date
*I understand that this release is for the specified test date(s) only.
**Verification of Pre Assessment Activity from South Plains College will be attached to score report
***Disclosure of Social Security Number is voluntary and is not required by state or federal law. The Social Security Number provided on this form will be used only to
identify test scores.
Updated 8/8/2016
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Form 79416: AUTHORIZATION TO RELEASE TEST SCORES FORM (South Plains College)

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Completed 27 July 2020

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