ACCUPLACER Scores Request Form

ACCUPLACER Scores Request Form

Testing Center | kwatson@sandburg.edu | 309.341.5323
The Family Educational Rights and Privacy Act of 1974 prohibits educational institutions from releasing Student records WITHOUT written consent from the student. This form is used to request a copy of your Test Scores from Carl Sandburg College.
Name*

First NameLast Name
Last four of SSN or 7 digit Sandburg ID#*
Date of Birth*

MonthDayYear
Current Phone Number*
Please enter a valid phone number in case there is a question regarding your request.
Return email address for confirmation receipt of your submission:*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please choose one preferred method of delivery per request:*

MailFaxE-mailI will pick up
I authorize Carl Sandburg College to release my test scores to the following:

Name of Institution

Street Address

CityState / Province

Postal / Zip Code
I authorize Carl Sandburg College to release my test scores to the following:
Name of Institution
Attention To:
If applicable
Fax Number:
Please enter a valid fax number.
Email:
example@example.com
Student Signature:*

Clear
Date*

MonthDayYear
Score reports are normally sent within 48 hours. There are no fees required to have scores sent. For additional assistance, contact the Testing Center, at 309.341.5323.

Office Use Only

Mailed Scores________ Faxed Scores_________ Other_________
Should be Empty: