Metropolitan State College of Denver - Assessment and Testing Center
Address: Tivoli Student Union, Room 347, Campus Box 99, 
                  P.O. Box 173362 Denver, CO 80217-3362 
                  Phone: (303) 556-3677; Fax: (303) 556-2140; 
                  URL: http://www.mscd.edu/~testing
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                 TESTING CENTER GENERAL PAYMENT FORM

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Print, fill in and send this form to Fax: (303) 556-2140
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Name 

Last: ________________________ MI: ________ First:_____________________

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Address

Street: ____________________________ City: ____________________________

State: ___________ Zip: ____________  SSN: ____________________________

Telephone: _______________________(W) & ________________________(H)

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Payment method: 

Credit Card: Discover:___; MC:___; Visa:____

Acct # _________________________ Exp. Date: ___________________________

Actual Name on the Card: ______________________________________________

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Check if apply the available tests:

_____ ACT Residual (202030-SASS-5610-1500); Date(s):___________________
        $32.00/test; no refund

_____ Education Writing Exam; Date(s):_________________________________
        (202020-SASS-5610-1500); 
        $40.00/test; no refund; Retest: ___ Yes; ___ No.

_____ ORAL Exam for Teacher Licensure; Date(s):________________________
        (202020-SASS-5610-1500); 
        $40.00/test; no refund 

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Check if apply the available services:

_____ Courtesy Proctoring; Date(s):____________________________________
        (202020-SASS-5610-1500); $25/tes; no refund
        (Call for Appointment Information First )

______ Miscellaneous Reschedule Fees;   Date(s):_______________________
       no refund

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Formed filled out by: _______________; Total amount paid: ______________