Please provide the following contact information:

First Name
Last Name
Date of Birth	Month _________ 01 02 03 04 05 06 07 08 09 10 11 12    Day _______ 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31    Year ________ Before 1925 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996
SMC ID #
Phone
E-mail

Please select one of the AVAILABLE appointments. You may only sign up for ONE test date. Multiple submissions will not be processed:

             

                     FRIDAY NOVEMBER 09, 2007--9AM                            

                             

Agreement

I understand that by submitting this form, I am registering for the Chemistry Challenge Exam for the date/time marked above. I am responsible for keeping this appointment and will notify the Assessment Center in-person, by calling 310-434-8049, or emailing to cancel, and that failure to notify the Center may result in refusal to reschedule an appointment in the future. I further understand that once my request is processed I will receive an email confirmation from an Assessment Center staff person. This form will be required to gain admission to the testing session.