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: ______________________      STUDENT ID# (EMPLID):________________________________

LAST NAME: ______________________________   FIRST: ________________________   MI: ______

STREET: _____________________________  CITY: ________________  STATE: _____  ZIP: _______

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

COURSE(S): _________________________________________________________________________

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, signed and dated, on a copy of your organization's letterhead:

  "I agree to serve as a proctor for __________________________________.  I certify that the information I provided on the Proctor Request Form is correct."

STUDENT:  Please send this completed form, your proctor's statement on letterhead, and the Exam Passes for your course to:        

Proctor Request - Attn: Course (e.g., GEO200)
Extended Learning Institute, Northern Virginia Community College
8333 Little River Turnpike, Annandale, VA 22003-3796
FAX (703) 323-3392 or Email scanned requests to:elicoursespecialists@nvcc.edu

Please allow 2 business days for processing. To check the status of a request call 1-888-4DL-NVCC or email elicoursespecialists@nvcc.edu.