Iowa Central Placement Test Score Request Form


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* indicates a required field

* First Name: A value is required.
* Last Name: A value is required.
  Former Name:
* SSN or Student ID: A value is required.
* Birth Date: A value is required.Invalid format. Must be in MM/DD/YYYY format.
* Phone: A value is required.Invalid format.A value is required.
* Address: A value is required.
* City: A value is required.
* State: Please select an item.
* Zip: A value is required.
  Country:
Send Placement Scores:
* Please select an item.
   College/Business Name
* Name/Attention: A value is required.
* Address: A value is required.
* City: A value is required.
* State: A value is required.
* Zip Code: A value is required.
   Country:
* E-mail to: A value is required.Invalid format.
* Confirm E-mail: A value is required.The values don't match.
Special Instructions
 
You will be contacted in 1-2 business days in order to complete the payment process.

By clicking the submit button, I give Iowa Central Community College permission to release my test scores to the institution(s) listed above.