Request for Release of Placement Test Scores

First Name *

Last Name *

Former Last Name

Student ID *

Birth Date *

Daytime Phone *

Email *

Address *

City *

State * - Select a State - Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code *

Send My Test Scores To

Name of Institution 1 *

Institution 1 Address *

Institution 1 City *

Institution 1 State * - Select a State - Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Institution 1 Zip Code *

In what format does Institution 1 want to receive the scores?

• Fax
• Email
• Postal Mail

Institution 1 Fax Number or Email

Institution 1 Attn: *

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Name of Institution 2

Institution 2 Address

Institution 2 City

Institution 2 State - Select a State - Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Institution 2 Zip Code

In what format does Institution 2 want to receive the scores?

• Fax
• Email
• Postal Mail

Institution 2 Fax Number or Email

Institution 2 Attn:

To complete your request, submit payment of $25

• Call 319-296-4417 or 800-670-4769, option 4
  -OR-
• Mail payment to:
  Student Services
  Hawkeye Community College
  1501 East Orange Road
  P.O. Box 8015
  Waterloo, IA 50704-8015

Allow 48 hours for your request to be processed.

By clicking the Send Request button, I give Hawkeye Community College permission to release my test scores to the institution(s) I listed above.