Request to Release Assessment Scores

Request to Release Assessment Scores
STUDENT INFORMATION
BMCC ID or SSN
Name

FIRST NAMELAST NAME
OTHER LAST NAMES USED
Address

Street Address

Street Address Line 2

CityState / Province

ZIP
Email
example@example.com
PHONE NUMBER
Format: (000) 000-0000.
DATE OF BIRTH

MonthDayYear
Date
College or Agency Information - Note: Scores cannot be sent to individuals
Name of College or Agency
Person or Department to Release Information to
Email Address of recipient
example@example.com
Click here to attach your Valid Photo ID (Required) Example: Valid Drivers License
File Upload

Valid Photo ID
Cancelof
Student Signature & Acknowledgement
STUDENT SIGNATURE: By completing and submitting this form, I verify that:
- I am the student that this request is being made for; and,
- The Photo ID provided is valid and not expired; and,
- Blue Mountain Community College has my permission to share my assessment scores with the college or agency listed above.
Student Signature
Date

MonthDayYear
Date
EEO Statement: Blue Mountain Community College is an equal opportunity educator and employer. For a complete EEO disclosure statement, please go to http://www.bluecc.edu/EEO

Blue Mountain Community College is an equal opportunity educator and employer
Should be Empty:

College or Agency Information - Note: Scores cannot be sent to individuals