Student Information

Student Name*
University ID Number*
Address*
City*
State*
Zip*
Telephone*	Day:  Eve:
E-mail Address*
Course Information
Semester Dates*	July August September October November December January February March April May June   2015 2016 2017 2018
Course Title*
Course Code*
Reminders » If you choose to utilize the Online Proctor Service (OPS) and take your course exam(s) online, this form is not necessary. Submitting a Proctor Request Form tells us that you wish to take the paper version of your exam(s). » This form must be submitted to the Office of Test Administration by the end of the first week of the semester. Keep a copy for your records. » Proctor information must be submitted for each course in which you plan to take a pen/paper exam. You may decide to take exams for some of your courses online and others in the paper format – that is your prerogative. But once you have made that decision, it will hold for the entire course. For instance, if you take the midterm in the paper format, the Office of Test Administration will automatically send the paper final to the proctor. Likewise, if you take the midterm online, we expect you to take the final online as well through OPS. » Verification will be sent to you via email when your proctor is approved. » You are responsible for any fees charged by your proctor. » Exams will be mailed directly to the proctor about two weeks before the official test week. All exams must be completed by the last day of the semester unless you have applied for and been granted an official course extension. » If you need information on a reasonable accommodation for a verified disability, contact the Office of Students with Disabilities at (609) 984-1141, ext. 3415 (voice) or (609) 341-3109 (TTY).
Proctor Information
Proctor Name*
College/library*
Title*
Address*
City*
State*
Zip*
Work Telephone*
E-mail Address*
Brief job description*

By submitting this form, I attest that all proctor information contained on this form is correct and conforms to the guidelines for suitable proctors. I have read the guidelines and agree to abide by all rules and regulations set forth by the University. I understand that any deliberate misstatement of fact may result in my dismissal from Thomas Edison State University and a grade of “F” being assigned for any and all courses—past and present—in which examinations were taken under such misstatement.