*For Internal Use Only

AE/LC Name*

AE Email*

CSM Name*

CSM Email*

Discipline*

Course Key*

Magellan Opt ID*

Digital Solution to be Class Tested*

IAC ISBN 13 (Instant Access Code ISBN)*

LMS Integrated?*

If yes, LMS used:

Instructor First Name*

Instructor Last Name*

Email Address*

Institution Name*

Institution Address (City/State)*

Institution Zip Code

Product in use today (Author, Title, Edition)*

Class Test Start Date (mm/dd/yy)*

IMPORTANT: Please allow 1 week for the class test request to be processed. Students should NOT be enrolled in the courseware at this time.

Class End Date (mm/dd/yy)*

Annual Enrollment*

Class test enrollment (# of students needing access)*

Describe how this will address your customer's objectives & any add'l info for marketing*

I would like a Faculty Partner to assist with this class test.

EXCLUDE from class test email communications