Select only ONE of the following test dates available--You may only sign up two weeks in advance of the test date.

Please fill out the required information below:

LAST NAME:

FIRST NAME:

MIDDLE INITIAL:  

DATE OF BIRTH: (MM) January February March April May June July August September October November December   (DD) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31   (YR)  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     

SMC student ID (required): 

Phone Number: (Please provide a valid phone number where you can be reached at.)

Email Address:  (An Email address is required only if you choose to have your appointment confirmation emailed to you. If you do not provide an email address or do not have access to an email account, you will be required to come in person to pick up your confirmation/appointment card prior to the date of the test.)

Have you attended Santa Monica College before (exclude Community Services classes)? Yes No

Are you a currently registered student at Santa Monica College? Yes    No 

Are you currently enrolled in or have you previously enrolled in a Chemistry class here at Santa Monica College? Yes    No

  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 or by calling 310-434-8049 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.