Assessment Results
Release Form
Submit completed form by email to mjctesting@mjc.edu, fax to (209) 575-6859,
in person or mail to Enrollment Services.
Note to Student: Assessment Results will only be sent to educational institutions. All requests must be authorized by
the student’s signature in accordance with Family Educational Rights and Privacy Act (FERPA) of 1974. Please allow up
to 5 business days for processing.
Student Information:
First Name: Middle Initial: Last Name:
MJC Student ID: w Birthdate: Phone Number:
MJC Student Email:
Current Address: City: State: Zip:
I hereby authorize Modesto Junior College to release my assessment results to:
College Name:
College Address: City: State: Zip:
College ID
(not MJC):
Type of Delivery:
(will not send to personal email account or fax)
Mail to address listed above. Pick up in Enrollment Services Oce
Fax: Email:
Student Signature: Date:
Oce Use Only
Processed By: Date:
MJC Enrollment Services • 435 College Avenue, Student Services Bldg. 1st Floor • Phone (209) 575-6853
10/2019_SJB
click to sign
signature
click to edit
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