Fillable Score Request Form Consent for the Release of (Alamance Community College)

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Score Request Form Consent for the Release of (Alamance Community College)

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Score Request Form
Consent for the Release of Confidential Information
Please fill out the following form to allow your test scores to be released.
Incomplete or inaccurate forms will not be processed.
I, _____________________, authorize ACC to release my placement test scores to the following
(Name of Student)
Name of Institution or Person: _____________________________________________________
Street Address: _________________________________________________________________
City: ______________________________________ State: __________ Zip Code: ___________
Fax Number (if applicable): _______________________________________________________
I understand that my records are protected under the Federal Confidentiality Regulations and
cannot be disclosed without my written consent.
_______________________________ ______________________________
(Signature of Student) (ID or Social Security Number)
______________________________ ______________________________
(Street Address) (Telephone Number)
_____________________________ ______________________________
(City, State, Zip Code) (Today’s Date)
Please return completed form to: Student Success, P.O. Box 8000, Graham, NC, 27253 or fax to:
(336)-506-4264
.
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Score Request Form Consent for the Release of (Alamance Community College)

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Completed 29 January 2021

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