Fillable TESTING SERVICES REQUEST FORM (Delta College)

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TESTING SERVICES REQUEST FORM (Delta College)

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DELTA COLLEGE TESTING CENTER
1961 Delta Road, A133
University Center, MI 48710
Phone: (989) 686-9182
Fax: (989) 667-2213
TESTING SERVICES REQUEST FORM
EXAMINEE INFORMATION
Name:
Address:
Telephone:
E-mail:
Appointment Preferences:
EXAM INFORMATION
Exam Name/Course Title:
Type (please pick one):
☐ CLEP ☐ Dantes/DSST ☐ Proctor
INSTITUTION INFORMATION (If Applicable)
Institution Name:
Instructor/Contact:
Phone Number:
E-mail:
Time Allowed:
Format (please pick one):
☐ Paper/Pencil ☐ Computer
APPOINTMENT INFORMATION
OFFICE USE ONLY – DO NOT WRITE
Exam Date: Time: Reschedule: Time:
DELTA COLLEGE ADMINISTRATION FEE: $35 PER TEST
Cashier – Deposit into Testing
Fees
Discover/MasterCard/Visa
(American Express not accepted)
Receipt #
Number
— — —
Amount
Expiration:
CVV:
Date
Cardholder Name:
Received by
Billing Address, State, Zip:
L:\PROJECTS\LLIC\Testing Center\Forms\Services Request form 2019.docx
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Completed 26 July 2020

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