Student Name:	Student Email:	Student ID:	Verified Identity:	Request_ID:Submit Date:
Former name:

Completion of this form authorizes the Testing Center to send all of your placement scores from Heartland Community College to the email addresses you indicate below.
Institution:   Institution Text Box	Authorized recipient email: Authorized recipient email Text Box
Authorized recipient name: Authorized recipient name Text Box	Confirm email: Confirm email Text Box
I understand by checking this box and typing my name below, I am authorizing the Testing Center to release test scores.
Type name below: Student signature Text Box