Texas Success Initiative (TSI)
Cross-Institutional Test Score Request Form

REQUESTOR INFORMATION

Student Name - First Name

Student Name - Last Name

Date of Birth

mm/dd/yyyy

TSU Student ID

For Example: T00000001

Phone Number

Phone

CONSENT AGREEMENT

I give my permission for Texas Southern University to retrieve TSI Assessment scores from the institution listed on this form and for those TSI Assessment scores to be applied to my registration records at Texas Southern University. I hereby knowingly, freely, and voluntarily waive any right or cause of action arising as a result of the transmission of my test scores from which any liability may or could accrue to Texas Southern University, the State of Texas, and any other governmental body, institution of higher education, or corporate entity which was associated with the transmission of the requested information. I understand it may take at least 48 to 72 hours for my test scores to be retrieved from the other institution.

Yes / No

TESTING SITE INFORMATION

College/Institution/Testing Site Name

ISD Name

Date of Testing Day

mm/dd/yyyy

Student Name used the day of testing

Student ID used at Testing Site

Upload files - test scores, a copy of ID and etc.

If you would like to upload a file(s), drag and drop the file(s) into the box below or click browse files.

Drop your files here

Signature

Please submit your full name which we will use as a form of signature.

Confirmation

Please confirm you understand that the above field is equivalent of a signature and confirms your consent.

Signature Date

mm/dd/yyyy

TSU CONTACT INFORMATION

TSI Inquiries

tsi@tsu.edu

University Testing Center

testing@tsu.edu

Send me a copy of my responses

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Texas Success Initiative (TSI) Cross-Institutional Test Score Request Form

REQUESTOR INFORMATION

CONSENT AGREEMENT

TESTING SITE INFORMATION

TSU CONTACT INFORMATION

Texas Success Initiative (TSI)
Cross-Institutional Test Score Request Form