Distance Learning - Testing Center Appt Request

Student Information

Last Name*:
First Name*:
Student ID # (8 digits)*:
Your E-Mail Address*:
Day Phone #:
Evening Phone #:

Test Information

Campus*:	(Which Testing Center are you going to?)
Course and Course #*:	(ex HIST 180)
Semester*:
Type of Exam*:

Instructor's Name is required for on-campus test only!
Instructor's Name:

This field is required for PACE/Telecourse students:
PACE/Telecourse Exam:

Speech students must fill out Film Titles!
Film Title 1:
Film Title 2:

Appointment Information

YOU MUST FILL OUT TWO (2) APPOINTMENT DAYS.

Before selecting a date and time consult the Testing Center Hours.

If you need an appointment today, please call the Testing Center instead of using this form.

Once you have completed this form you will receive an e-mail within 24 hours confirming your appointment. You must check your e-mail within this period to confirm the appointment.

Appointment Day 1:		Appointment Day 2:
Date* (M/D/YYYY):		Date* (M/D/YYYY):
Time*:		Time*:

Comments/Additional Information: