Placement Test Request Form

Placement Test Request Form
Iowa Lakes cannot send ACT scores. Please contact ACT directly (www.act.org) to request scores.

Fee: In order for scores to be sent, a $15 fee is required. Please pay in the form of check, cash, or credit card at any of our five campuses. You may also pay over the phone by calling 712-852-5263. Once payment is received, scores will be sent (through mail or email) to location indicated on the form.
Name

First NameLast Name
Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Student ID (if known)
Student Email
example@example.com
Which test score(s) are you requesting?
Where did you take the exam?
Name of High School where you took the exam:
School Information
Send scores to:
Institution Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email of School Representative to Receive Scores
example@example.com
Fax Number
Contact Person:
Student Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

School Information