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Test Entry Request

This form is for requesting to have a test record entered in MDConnect. It is not for scheduling an exam at MDC or requesting a test score to be entered at a future date.

Are you the student making the request or other?*

Student Other (Staff, Parent, etc.)

Is this request associated with an application to the Honors College, School for Advanced Studies, or another MDC program?*

Honors College School for Advanced Studies Another MDC program

Requester Email*

Requester Name*

First Name

Last Name

Requester Middle Name

Requester Phone Number*

Reason for Request

Student Name*

First Name

Last Name

Student Middle Name

Date of Birth*

Student Phone Number*

Student Email*

Name

First Name

Last Name

Enter Test Report Form Number. ( see bottom right corner of the Test Report Form)*

Enter Score Report Code*

Enter Verification Code *

Enter TOEFL Appointment Number*

Enter the ACTFL Certificate Code:*

Where did the student take the FCLE?*

High School College or University

Name of the High School or Institution:*

Examinee ID number on score report

Test Date*

Comments (Optional)

Please upload a copy of the test score report in a PDF format

No File Chosen

File uploads may not work on some mobile devices.

Do you have an additional Test Entry Request?*

Yes No

Please specify test name*

Test Name*

ACT AP IB Cambridge AICE CLEP TOEFL SAT Other

Test Date*

Examinee ID number on score report

Comments (Optional)

If available, please upload a copy of the 2nd test score report in a PDF format

No File Chosen

File uploads may not work on some mobile devices.

Do you have an additional Test Entry Request?*

Yes No

Test Name*

ACT AP IB Cambridge AICE CLEP TOEFL SAT Other

Please specify test name*

Test Date*

Examinee ID number on score report

Comments (Optional)

If available, please upload a copy of the 3rd test score report in a PDF format

No File Chosen

File uploads may not work on some mobile devices.

Please provide information below for Cambridge AICE

Centre Number*

Candidate Number*

Series Test Date*

Short Answer

High School Contact Information

Please fill out your High School contact information below.

High School Name

Counselor Name

First Name

Last Name

Counselor Email

Counselor Phone

High School Address

Address Line 1

Address Line 2

City

State

ZIP Code