Placement Test Scores Request Form

Placement Test Scores Request Form
Your Full Name

First NameLast Name
Your Email
example@example.com
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Student ID Number
BCCC Student ID
Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Your Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date Tested

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I HEREBY AUTHORIZE THAT A COPY OF MY PLACEMENT TEST SCORES BE RELEASED TO:
Name of School or Agency to receive placement test scores
School or Agency to receive placement test scores*
School or Agency Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
School or Agency Email Address
example@example.com
Typing your name in this field will act as your official signature.
Full Name*
Allow up to 10 days for processing.
Should be Empty: