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During the course of your education program, you are given examinations. These examinations must be monitored by designated individuals (Proctors) capable of supporting the students examination needs and meet the requirements outlined below.

• Must be a teacher, instructor, supervisor, librarian, or counselor and at least 21 years old. No relation to the student.
• Be able to monitor the examination from start to finish.
• Will be available to receive examinations from the University and coordinate with the student on the date, time, and location of the exam.
• Will be able to mail the completed exam in the addressed envelope.
• Will agree to sign the Proctor Statement of Responsibility and mail back to the University.  (Print a copy of this web page)

If at any time you must change a Proctor, notify the University and a new statement will be mailed to your new designated Proctor.

I,  (Print Full Name) ____________________________, agree to proctor examinations for (Students Full Name) _______________________ .

Please check the Yes or No block and initial after each statement block:

• I agree to follow specific guidelines provided per examination. Yes No ______
• I agree to coordinate date, time, and location to administer the exam. Yes No______
• I agree to mail the exam in the provided envelope upon completion. Yes No______

Proctor Information:

• A. Occupation: _________________________
• B. Mailing Address:

(Street, PO Box, Apt #) ____________________________

(City)___________________ , (State or Country)________, (Zip Code)__________

• C. Work Phone: (      ) ____ - ______
• D. Email Address (If Available):________________________

 _____________________________

(Signature)