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Accuplacer Distance Location Form

Request to Take Accuplacer at a Remote Location

          CNM           

Attachment A

Request to Take ACCUPLACER® at a Remote Location

 

Student’s Name: __________________________________________________

Student ID#: __________________________

Address:_________________________________________________________

City, State, Zip: ______________________, ______ __________________

E-mail: _________________________________________________

Phone # : (______) ______ - _________

 

Please fill out the following information regarding the proctor who has agreed to administer/proctor the ACCUPLACER tests to you. It must be someone from a test center at an academic institution. (All sections must be filled in!)

Proctor’s Name: ___________________________________________________

Institution:________________________________________________________

Mailing Address:____________________________________________

City, State, Zip: ____________________, _________  ______________

Phone: (______) ______ - _______ Fax: (______) ______ - ________

E-mail: ___________________________________________________

 

Please fill out the above form and return to:

Bob Watson
Assessment Testing Supervisor
(505) 224-4000 ext. 52015                                              

Fax: (505)224-3258 Email: jwatson40@cnm.edu