ACT VOUCHER REQUEST FORM

Please complete the following voucher request information. YOU MUST HAVE AN APPLICATION ON FILE TO RECEIVE ANY SERVICES. If you're new to the project, please visit www.deltastate.edu/cced/delta-educational-opportunity-center/, and click FORMS to submit an application.

Name

First NameLast Name

Test date requested:*

Type of voucher requested:

No WritingWith Writing

Phone:*

Area CodePhone Number

Alternative Phone:

Area CodePhone Number

Email*

example@example.com

ACT Account Information
ACT email* Type pwd here*

What county do you reside in?*

What school do you attend?*

Preferred testing location, if available:

Special Accommodations Needed?*

YesNo

For seating purposes, please select one:*

Right-handedLeft-handed

What colleges/universities would you like to receive your scores? You may list up to 4.
Spell out names completely. For example, MSU could mean Mississippi State
or Michigan State.
college college college college

If this is your first time registering, please upload a photo here for your admission ticket. Your registration is not complete without a photo.

Browse Files

I confirm that I do not have access to an ACT fee waiver through my school (if applicable) or an ACT test voucher through another entity/organization and cannot afford the fees for ACT testing.

Signature

Date

In accordance with Title IX, Delta State University is committed to maintaining a learning and working environment free from sexual and gender-based discrimination, harassment, sexual assault, sexual exploitation, sexual intimidation, stalking, dating violence, domestic violence, or any other behavior that is non-consensual or has the purpose or effect of coercing a person or persons. For questions or concerns about Title IX, please visit http://www.deltastate.edu/policies/policy/university-policies/employment/employee-responsibilities-and-standards/sexual-harassment/ or contact Deidra Byas, Title IX Coordinator at (662)846-4690 or email titleix@deltastate.edu."