Authorization to Release
Placement Test Scores
Please mail or fax the completed and signed form to HFC Course Placement office. There is
no charge for this service. Incomplete forms will delay processing. Scores that can be
requested include Compass, Accuplacer and CaMLA.
Henry Ford College
Welcome Center Assessment Office
5101 Evergreen Road
Dearborn, MI 48128
Fax: (313) 317-4112
Student Information
Student ID Number: ____________________
Date of Birth: ____________ Phone Number: ____________________
Last Name: ____________________ First Name: ____________________
Middle Initial: ____________________
Previous/Former Name(s), if applicable: ____________________________________
Current Address: ____________________________________ City: ____________________
State: ____ Zip Code: ____________________
Mailing/Fax Information
Authorization to Release
Placement Test Scores
a copy of all of my Placement scores to the following institution:
Institution Name: _______________
Institution Address(if by mail):
Institution Fax Number (if by fax):
NOTE: By signing and completing this form, you are authorizing Henry Ford College to disclose
your test results to the institution at the fax number documented above. Please NOTE the Course
Placement office staff will not verify the accuracy of the recipient information you are providing.
Student Signature: ____________________________________ Date: ____________________
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