Transcription of ACT Test Information Release Order Form
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ACT Test Information Release Order Form
Test Information Release Order form 2017 2018 ACT, Restricted when data is present. 2017 by ACT, Inc. All rights reserved. This is a new permanent addressPLEASE PRINTName of Examinee (as given when the ACT test was taken) Date of BirthStreet AddressCity State/Province ZIP/Postal Code ( )ACT ID Telephone NumberLocation of test center where the ACT test was takenI understand that by signing below, I consent to the ACT Privacy Policy ( ), which is incorporated into this form by reference, including consent to the collection of personally identifying Information and its subsequent use and disclosure. International Examinees: By signing below, I am also providing my consent to ACT to transfer my personally identifying Information to the United States to ACT or a third-party service provider for processing, where it will be subject to use and disclosure under the laws of the United States. I acknowledge and agree that it may also be accessible to law enforcement and national security authorities in the United SIGNATURE of the examinee* Payment must be made in US dollars drawn on a US or US affiliate bank.
Test Information Release Order Form 2018–2019 ACT, Inc.-Confidential Restricted when data is present. © 2018 by ACT, Inc. All rights reserved.
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