Student Exam Request Form

Proctored Exam Information for Online Students


Student Information
Student Name: (First and Last)
Preferred Email Address:
(so we can send you a confirmation)
Campus Email Address:
Student ID (917#):
Student Phone Number
Instructor Name:
Course Name:
Course Number:
Name of Testing Official:
Phone Number of Testing Official:
Email of Testing Official:
Name and Address of Testing Center:
Scheduled Examination Date:
Scheduled Examination Time:

Please review your information above before submitting.