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20122013 Request for ACT Arranged Testing

Available only during six designated three-week testing windows. See request form for dates and deadlines.
Students approved for Arranged Testing must test with both standard time limits and a regular type (10-point) test booklet. ACT reviews requests for arranged administrations for the following students ONLY: 1. Students whose religious faith prohibits Saturday testing AND a non-Saturday test center is not scheduled within 50 miles of their home for ANY test date. See the test center listings on www.actstudent.org. 2. Students in countries where ACT does not have a test center scheduled for ANY test date. Students are encouraged to travel to a test center in a nearby country if there is a center scheduled within reasonable traveling distance. Students visiting in countries where there are no test centers are encouraged to test before they leave or after they return to the United States or Canada. 3. Students in the US, US territories, Puerto Rico, and Canada who do not have a test center scheduled within 50 miles of their home for ANY test date. 4. Students who are confined to a hospital or the home due to medical reasons, or to a correctional institution, on ALL test dates. ACT will NOT consider Arranged Testing because a student was ill, had a conflict on an established test date, or is not fluent in English. ACT will not approve Arranged Testing when the student does not have an international test center scheduled within 50 miles on any test date IF there are ANY test centers scheduled in the students country for ANY test date. Test scores achieved under the supervision of an individual who does not satisfy ALL the requirements will be cancelled automatically without refund.

Test Options
Two test options are available: the ACT (No Writing), which is made up of multiple-choice tests in English, mathematics, reading, and science; or the ACT Plus Writing, which also includes a 30-minute Writing Test. Taking the Writing Test does not affect the subject area scores or the Composite score. For more information about the ACT Writing Test, see www.actstudent.org.

Scheduling the Administration

Testing Windows. Arranged Testing must be administered on one day during one of the designated three-week testing windows listed on the request form. The September window is available only within the US, US territories, Puerto Rico, and Canada. ACT Plus Writing is available during the February window only within the US, US territories, Puerto Rico, and Canada. Testing Time. Schedule testing at a time mutually agreeable to the student and supervisor that allows for an uninterrupted session of approximately 3-1/2 hours for the ACT (No Writing) or 4 hours for the ACT Plus Writing. ACT prefers that testing be scheduled as the first activity of the morning. The tests must be administered in a single session on one day. Testing procedures allow a short break after the second test. Students taking the ACT Plus Writing will have time to relax and sharpen their pencils before the Writing Test. The test session may NOT be interrupted by longer breaks for meals or other activities. If it is, the answer document will not be scored or scores will be cancelled Test Location. Testing must be done at the school. IF the student is confined to the home or another location, you must request authorization from ACT to administer the tests at that location. Attach a statement to the request form explaining why the alternate location is necessary and document your plans for securely transporting the test materials and ensuring standardized testing conditions at the proposed location.

Testing for Students with Disabilities

Do not request Arranged Testing for students who need test accommodations due to a professionally diagnosed and documented disability. ACT does not provide any test accommodations through Arranged Testing. Instead of completing this form, review Students with Disabilities on www.actstudent.org for eligibility requirements and instructions for requesting accommodations. Do not test students approved for Arranged Testing and students approved for Special Testing in the same room. Do not test students approved for Arranged Testing with students testing under standard time conditions through National or International Testing.

Submit your request as early as possible to provide ample time for review and follow-up correspondence. Your request and payment must be postmarked (received, if outside the US or Canada) no later than the deadline listed on the request form for your preferred testing window.

Arranged Testing Supervisor

It is the students responsibility to ask a teacher or counselor at the high school, college, or university he or she is currently attending to serve as the test supervisor. (If the student is not currently attending school, ACT recommends contacting the testing department at a nearby college or university.) The test supervisor must: 1. Be proficient in English. 2. Be experienced in testing and measurement. 3. Be a staff member of the institution where the arranged administration will take place. 4. Have control over locked, limited-access storage at the institution to secure the test materials. 5. Agree to administer the tests according to policies and procedures in the ACT Supervisors Manual Arranged Testing sent with the test materials. To protect both the student and the test supervisor from questions of possible conflict of interest, the following conditions must also be met. The test supervisor must: 6. Not be a relative or guardian of the student. 7. Not be a private consultant or individual tutor whose fees are paid by the student or students family. 8. Not be engaged in test preparation activities for the ACT during the current academic year. Only if the school district contract specifically requires the teacher or counselor to participate in school-sponsored test preparation courses may that person serve as supervisor. 9. Not be involved in coaching athletics (required only if the student participates in athletics).

How to Contact ACT

Address: ACT Arranged Testing 301 ACT Drive P.O. Box 168 Iowa City, IA 52243-0168 USA Office hours: 8:30 a.m.5:00 p.m., central time, MondayFriday Phone: 319.337.1510 Fax: 319.339.3039 E-mail: arranged@act.org


Retest Restrictions
A student may take the ACT no more than 12 times total. A student may test only once per national, international, or state test date, or Arranged Testing window. If the retest restrictions are violated, the scores will be cancelled automatically without refund.

Fee Payment
The test fee, which includes reports for up to four valid college codes listed on the answer folder is $35.00 for the ACT (No Writing) or $50.50 for the ACT Plus Writing. Payment of the additional $30.00 international surcharge is required for tests administered in locations other than the US, US territories, and Canada, for a total of $65.00 for the ACT (No Writing) and $80.50 for the ACT Plus Writing. Payment must be in the form of a personal check, cashiers check, or money order payable to ACT in US dollars and drawn on a US or US affiliate bank. Cash will not be accepted. A ticket for a National or International Test Date from the current testing year will be accepted as payment if submitted with the request form and payment of an additional $21 fee.

H. Return of Request Form Follow these steps: 1. Keep a photocopy of the completed request form for the students files. 2. Check the form for completeness and both signatures; incomplete and/or unsigned forms will not be processed. 3. Include all documentation specified in Section D. 4. Include the students full fee payment. 5. Mail the form to the address listed. Do not have the student register. 6. Send the request form as far in advance as possible. The form must be postmarked (received, if outside the US or Canada) no later than the deadline for your preferred testing window. 7. Keep this brochure for your reference.

Response from ACT

If the form is missing any information, signatures, or full payment, the request will not be processed. If Arranged Testing is approved by ACT, test materials will be shipped to arrive no later than one week prior to the first day of the testing window. The student will NOT receive a ticket.

*NOTICE: This is notification that when you pay by check you are authorizing ACT,
Inc., to convert your check to an electronic entry. When we use this information from your check to make an electronic funds transfer, funds may be withdrawn from your account as soon as the same day you make your payment, and you will not receive your check back from your financial institution. If your check is returned to us due to insufficient or uncollected funds, it may be re-presented electronically and your account will be debited.

Assignment of Test Materials

Test materials may be used ONLY for the student(s) listed on the Test Materials Distribution List and may NOT be transferred to any other location or student. If the student(s) does not test, the test materials must be returned to ACT immediately with an explanation as to why the materials were unused.

Instructions for Completing the Request Form

The test supervisor must submit a Request for ACT Arranged Testing for each student. Incomplete forms, forms not signed by both the test supervisor and student (or parent/guardian if the student is younger than 18), and forms without full payment will not be processed. A. Student Information If the student has taken the ACT previously through Arranged Testing, enter the month and year of the most recent administration. B. Supervisor Mailing/Contact Information The name and address of the institution where you work is required. If you are not employed at the school the student attends, attach an explanation of your relationship to the student. Be sure to include your professional title (e.g., counselor, director), street address (for courier shipments), P.O. Box (if required for mail to reach you), daytime telephone number, and e-mail address or fax number (if you have one). C. Test Option and Testing Window Mark only one test option and select a testing window. You must submit the request form by the deadline listed or you may not be approved to test during your preferred window. D. Reason for Arranged Testing Check one. Students whose religious faith prohibits Saturday testing must submit a letter from their cleric or a notarized statement to verify the prohibition. Students who are confined to their home or another location on all test dates must include documentation by a qualified professional to support the diagnosis as well as verify the length of their confinement. Copies of diagnostic records and a copy of the homebound plan filed with the school must be submitted with the request form. Students with no test center in the country for any test date or no test center within 50 miles (US and Canada only) on any test date must provide an accurate mailing address. If ACT determines that the student has a test center scheduled on any test date within 50 miles (or within the country outside the US or Canada), Arranged Testing will be denied and the student must register to test through National or International Testing. ACT will not automatically register the student. E. Supervisor Statement Sign and date your agreement to the conditions listed. The name signed must be the same as the person listed in Section B. F. Student Statement The student must read and sign the statement. If the student is younger than 18, a parent or legal guardian must sign. G. Fee Payment The form will not be processed without full payment.

Answer Folder(s)
A Universal Answer Folder for each student will be shipped to the test supervisor. Identifying information (required), responses to the ACT Interest Inventory and Student Profile Section (optional sections), and college choices (up to six) must be recorded on this folder prior to test day. Answers to the multiple-choice tests will be recorded on this answer folder on test day. If the student is taking the ACT Plus Writing, a Universal Plus Writing Answer Folder will also be included.

If the Student Does Not Test

The test fee for the ACT (No Writing) and international surcharge (if applicable) are nonrefundable, even if the student does not test. Test Date Change: A student who does not break the test booklet seal(s) within the designated testing window may request a Test Date Change. To do so, the student and supervisor must sign a written request specifying the new testing window and submit it with payment of the $21 fee. The request must be postmarked by the deadline for the new testing window. Test Date Change requests will not be considered until after ACT receives the unused test materials. Refund Request: A student who registered and paid for the ACT Plus Writing who does not take the Writing Test may request a refund of the $15.50 Writing Test fee by writing to Arranged Testing. Refunds are not issued until after ACT receives the unused test materials. Refund requests for the 20122013 testing year received after July 31, 2013, will not be honored.

Each time a student wishes to test through Arranged Testing, a new request form must be submitted with full payment for the preferred test option and any required supporting documentation.

Supervisor Compensation
Only the person who administers the tests will be compensated. ACT will pay the test supervisor $106 for the administration of the ACT (No Writing) or $116 for the ACT Plus Writing. ACT treats all testing staff as independent contractors. Therefore, wages are not subject to income tax withholding and Social Security deductions. ACT reports the income to the IRS only if payments to an individual exceed $600 in a given year. A payment report form will be sent with the test materials.

Score Reports
Reports for the ACT (No Writing) are normally mailed within 24 weeks after ACT receives the answer folders; score reports for the ACT Plus Writing are normally mailed within 36 weeks. The Test Location is reported as School.


To be completed by the Test Supervisor. Please type or print clearly. A. STUDENT INFORMATION
Last Name First Name Middle Initial

C. TEST OPTION (Mark one.)

n ACT (No Writing) n ACT Plus Writing (not available during February testing window outside the US and Canada)
TESTING WINDOW (Mark one and submit your request no later than the postmark deadline for that windowreceived if outside the US and Canada.) Testing Window Postmark Deadline Aug. 7, 2012 Sept. 21, 2012 Nov. 2, 2012 Jan. 11, 2013 Mar. 8, 2013 May 3, 2013

Street Address

Apartment No.

City, State/Province, ZIP/Postal Code

Country (if outside US)

Phone Number (with Area Code)

Date of Birth

E-mail Address

High School Code or College Code (if attending)

n n Oct. 27Nov. 18, 2012 n Dec. 830, 2012 n Feb. 9March 3, 2013 n Apr. 13May 5, 2013 n June 830, 2013
Sept. 830, 2012* include any required documentation.)

*September testing window available only in the US and Canada.

Date of Previous ACT Arranged Testing (if applicable)





n (04) n (05) n (08) n (06) n (09) n (10)

Religious Faith Prohibits Saturday Testing AND No Non-Saturday Test Center Established for Any Test Date Within 50 Miles. Include letter from a cleric or a notarized statement to verify the prohibition. No Test Center in the Country for Any Test Date. Within the US or Canada only, NO Test Center Established for Any Test Date Within 50 Miles. Homebound (confined to home due to medical reasons) on All Test Dates. Include a copy of the homebound plan filed with the school and documentation of the diagnosis/length of confinement. Confined to a Hospital on All Test Dates. Include documentation to support this accommodation. Confined to a Correctional Institution from September 2012 through June 2013.

Detach here before mailing.

2. 3.

Professional Title 4. School (if not the students school, must attach explanation) 5. 6. P.O. Box (if required)

Street Address (required to ship test materials)

City, State/Province, ZIP/Postal Code

Country (if outside US)

Phone Number (with Area Code)

Fax Number (with Area Code)

E-mail Address (required)

E. SUPERVISOR STATEMENT (Signature required for ALL requests.) I certify that I personally meet ALL the requirements for test supervisor specified by ACT (see page 1, Arranged Testing Supervisor) and that I or a member of my staff who also meets the same requirements will administer the tests in accordance with the ACT Supervisors Manual sent with the test materials. I will ensure that the test materials are kept secure and confidential, used for this student only and not transferred to another student or location, and returned to ACT immediately after testing.

Supervisors Signature


F. STUDENT STATEMENT (Signature required for ALL requests.) I verify that the information provided on this form and in the attached documentation, if any, is accurate to the best of my knowledge. I authorize the release of any documentation attached to ACT.

Students Signature (parent or guardian must sign if student is under 18)


G. FEE PAYMENT. The test fee for the selected test option (and the international surcharge, if applicable) must be submitted with this form or it will NOT be processed. Fees are: ACT (No Writing) $35.00; ACT Plus Writing $50.50. Tests administered in locations other than the US, US territories, and Canada require an additional $30.00 international surcharge$65.00 total for ACT (No Writing) and $80.50 for ACT Plus Writing. H. RETURN OF REQUEST FORM. Follow the steps on page 2. Do not have the student register. Detach and mail this completed form, any required supporting documentation, and full payment to: ACT Arranged Testing, 301 ACT Drive, P.O. Box 168, Iowa City, IA 52243-0168, USA. Faxed forms will not be accepted. 3