Placement Testing Registration Form

* = required fields.

Student ID/M Number (optional):

*First Name:
Please enter your first name.

*Last Name:
Please enter your last name.

*Phone:
Please enter your phone number with area code. Please enter a valid phone number 000-000-0000.

*E-mail:
Please enter a valid e-mail address, for example jdoe@yahoo.com
Please call 315-731-5802 for assistance if you do not currently have an email address

*Have you taken SAT's?:
Yes No

Please make a selection.

*Have you taken ACT's? :
Yes No

Please make a selection.

Disability-Related Accommodations Needed (calculators are available for all students):
None (no disability) Extended Time Reader

Word Processor Multiple Testing Sessions Mobility

Other (Someone will contact you to discuss your needs)
Please make a selection.

You are scheduling for:
Date: Friday, January 18,2013
Time: 9:00am

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Utica 1101 Sherman Drive Utica, NY 13501 315.792.5400 Rome 1101 Floyd Ave., Rome NY 13440 315.339.3470
An equal opportunity educational institution affiliated with the State University of New York.
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None (no disability)	Extended Time	Reader
Word Processor	Multiple Testing Sessions	Mobility
Other (Someone will contact you to discuss your needs)