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. For students who cannot travel to a campus testing center: incarcerated students should suggest an educational officer or counselor as their proctor; disabled and other students who have extenuating circumstances which prevents them from going to a campus 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.

STUDENT AND COURSE INFORMATION (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: ________________________________________

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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: ( ) _________________________

PROCTOR: Please attach a copy of your organization's letterhead with the following statement, the date, and your signature: