Optical Mark Reading Services
OMR REQUEST FORM
Please print, fill out and include with your OMR Services order.

NAME:(Last)_______________________________________(First)__________________________________

DEPARTMENT:_____________________________________   PHONE: _____________________________

CAMPUS BOX:___________________                                  TODAY'SDATE:_______________________

OFF CAMPUS ADDRESS:__________________________________________________________________

RECORD FORMAT (OUTPUT)

We now can convert scanned data files into the following formats. You should only check a format
if you are processing the data yourself. Otherwise leave blank.

_____ FIXED LENGTH                                                      _____ SHEET COMPILE (OLD SCANNER)

DATASET NAME:___________________________________________________________________________

Last updated 02/01