Make sure the information entered is accurate 

First Name:

Last Name:

Chipola Student ID:

Are your test records under a different name?

Name on test record while attending Chipola College:

Date of Birth:

Mobile Phone Number:

Current Email Address:

Test Information

Please select the test type:

Please list the name of the test: 

Date of Testing Month:

What month did you complete this test?

Year the test was taken:

Receiving Institution

Name of Institution:

Name of Contact Person for this institution:

Phone Number for Institution Contact:

How should we send it?

Institution Email Address:

Institution Street Address:

Institution City, State & Zip Code:

Authorization & Submit

I willingly and knowingly authorize Chipola College Testing Center to release the test information specified above to the institution listed. I understand that under the Family Educational Rights and Privacy Act (FERPA), my test records are protected educational records and that I have the right to revoke this authorization in writing at any time by contacting the Testing Center.

Do you give authorized permission?

By submitting this form electronically through MyChipola, I certify that the information provided is true and correct. In accordance with the Electronic Signatures in Global and National Commerce Act (E-SIGN Act, 15 U.S.C. § 7001), I understand and agree that my authenticated login and submission of this form constitutes my legal electronic signature.