South Plains College – Reese Center
Testing and Learning Center
819 Gilbert Drive Lubbock, TX 79416
Phone: (806) 716-4631 or 716-4689
Fax: (806) 716-4704
DUAL CREDIT AUTHORIZATION TO RELEASE TEST SCORES
Date: ____________________
*Test Date(s): _______________________
I, _____________________________________, hereby authorize South Plains
(Print Student’s Name)
College to send my ACCUPLACER test scores to ______________________________
(Print High School Administrator’s Name)
at ___________________________________. The FAX number at this school is
(Name of High School)
_______________________.
(Fax Number)
________________________ __________
(Student’s Signature)
(Date of Birth)
______
_______________________
(Age)
(**Student Social Security Number)
(Parent /Legal Guardian Signature if Student is 16 Years of Age or Younger)
*I understand that this release is for the specified test date(s) only.
**Disclosure of Social Security Number is voluntary and is not required by state or federal law. The Social
Security Number provided on this form will be used only to identify test scores.
7/25/16