Grand Rapids Community College
Request to Release Accuplacer Placement Test Records
This form is to be used if you would like Grand Rapids Community College to forward a copy of your test
results to another college or institution. Your request will be processed within 48 hours of the time that
it is received.
Complete this form and return it to the place indicated at the bottom. All sections must be completed
and student’s signature must be on this request.
Student name: _________________________________ GRCC Student ID# ________________
Address: _____________________________________________________________________
City: ________________________________ State: ____________ Zip Code: _______________
Email: _______________________________________ Phone: __________________________
Signature: ____________________________________________________________________
Please provide the following information regarding the institution to which you wish to have your test
results forwarded, as well as the method that you want the report sent.
Check one: U.S. Mail _____ Fax _____ Email _____
Institution/college: ____________________________________________________________
Attention: ____________________________________Fax: ____________________________
Mailing address: _______________________________________________________________
City: _______________________________ State: _____________ Zip Code: _______________
Email: _______________________________________ Phone: __________________________
Please return to:
Enrollment Center/Accuplacer Testing
Grand Rapids Community College
143 Bostwick Ave. NE
Grand Rapids, MI 49503
Phone: 616-234-4865 / Fax 616-234-3200 / Email:
This form can be faxed, mailed or sent via Email (PDF)