* All form fields are required  
Student Name
Student ID or Driver's License #
Photo Identification Type
Assessment Type Administered
Course Prefix
Course Number
Course Section
Course Title

Instructor Email
Facility Name
Facility Phone Number

By checking the following boxes and submitting this form, I am confirming that:

I have supervised the student named above and testify that the student did not receive any assistance or use any materials unless specified in the written instructions from the course instructor.
I admitted the student to the examination after checking his/her picture identification. I collected all notes, worksheets, and other materials after administering the examination. I accept full responsibility for the security of this examination.

Proctor Name
Proctor Email
Proctor Initials