Proctor Request Form
For students who cannot travel to a campus testing center, the Extended Learning Institute requires that a proctor be a staff member at a testing center at a college or university.  Proctors cannot be a family member, employer, or someone with whom the student works.  Incarcerated students should suggest an educational officer or counselor as their proctor.  Disabled and other students who do not have access to an educational institution should suggest an alternative proctor, preferably an educator.  Requests for proctored exams and proctors must be approved by ELI.  ELI reserves the right to reject requests or proctors for any reason.  For approved requests and proctors, exams will be sent to the proctor.  For denied requests or proctors, an ELI staff member will contact the student.  If the proctor charges a fee, payment is the student’s responsibility.

	STUDENT AND COURSE INFORMATION (Student: Please print or type.)

DATE: _________________      SOCIAL SECURITY #: _______________________________________

LAST NAME: ________________________________   FIRST: ______________________   MI: ______

STREET: _____________________________  CITY: _______________  STATE: _____  ZIP: ________

PHONE #  HOME: (        ) _______________________  WORK: (        ) __________________________

COURSE NUMBER: ______________ COURSE NAME: ______________________________________

REASON FOR REQUESTING A PROCTOR: _______________________________________________

___________________________________________________________________________________

YOUR SIGNATURE:   _________________________________________________________________

	PROCTOR INFORMATION (Proctor: Please print or type.)

PROCTOR'S LAST NAME: __________________________  FIRST: ____________________  MI: ____

TITLE:___________________________________  ORGANIZATION: ___________________________

STREET: _____________________________  CITY: _______________  STATE: _____   ZIP: ______

COUNTRY IF NOT U.S.: ________________________  WORK PHONE: (        ) ___________________

EMAIL ADDRESS: ____________________________________________________________________

PROCTOR: Please include the following statement on a copy of your organization's letterhead.  Be sure to include the date and your signature: 
	"I agree to serve as a proctor for __________________________________.  I certify that the information I provided on the Proctor Request Form is correct."

STUDENT:  Please detach this form with the Exam Passes on back, attach your proctor's statement on letterhead, and send to:	
Proctor Request - Attn:  SPD 141
Extended Learning Institute
Northern Virginia Community College
8333 Little River Turnpike
Annandale, VA 22003-3796

Or you may FAX this form, a copy of the Exam Passes, and your proctor’s statement to (703) 323-3392.