Rev 3/28/19 jmk
P L A C E M E N T R E C O R D S R E Q U E S T F O R M
1. Print clearly.
2. Return completed form to your campus:
Wenatchee: the Educational Planning & Testing Center on the first floor of Wenatchi Hall or email it to
Omak: the front desk in the Administration Building or email to firstname.lastname@example.org or email@example.com.
3. There is no charge for this service. WVC Testing Center staff will process your request within five business days.
Last First Middle
Previous Names ____________________________________________ Date of Birth _______________________
Student ID and/or Social Security Number _________________________________________________________
Approx. month/year tested ___________________________ Phone ____________________________________
RECIPIENT CONTACT INFORMATION
Where would you like your placement records sent? ________________________________________________
Contact information (fax number/email address) ___________________________________________________
Mailing Address _____________________________________________________________________________
I give Wenatchee Valley College permission to release my placement records to the above named recipient.
I authorize communication with said institution/person.
Signature of person who tested (required) ________________________________________________________
Date (required) ______________________________________________________________________________
Wenatchee Valley College is committed to a policy of equal opportunity in employment and student enrollment. All programs are free from discrimination and harassment against any person because of
race, creed, color, national or ethnic origin, sex, sexual orientation, gender identity or expression, the presence of any sensory, mental, or physical disability, or the use of a service animal by a person with
a disability, age, parental status or families with children, marital status, religion, genetic information, honorably discharged veteran or military status or any other prohibited basis per RCW 49.60.030, 040
and other federal and state laws and regulations, or participation in the complaint process. The following persons have been designated to handle inquiries regarding the non-discrimination policies and
Title IX compliance for both the Wenatchee and Omak campuses: To report discrimination or harassment: Title IX Coordinator, Wenatchi Hall 2322M, (509) 682-6445, firstname.lastname@example.org. To request disability
accommodations: Student Access Director, Wenatchi Hall 2133, (509) 682-6854, TTY/TTD: dial 711, email@example.com.
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