UTB Test Proctoring Form for Online Students

STUDENT'S INFORMATION

Student's ID Number:
Student's Name:
Student's Email:
Student's Phone:
Course Number:
Course Name:
Instructor's Name:

EXAM DETAILS

Date:
Time:	8:00 a.m. 9:00 a.m. 10:00 a.m. 11:00 a.m. 12:00 p.m. 1:00 p.m. 2:00 p.m. 3:00 p.m. 4:00 p.m.
Name of Testing Center:
Web Address for Testing Center:
(not just the College or University web address)
Name of the Community College, College or University:
Able to support online testing?	Yes No

(Must be affirmative if your test is offered online. Check with your instructor if you are uncertain as to whether your test is an online test.)

PROCTOR'S INFORMATION

Proctor's Name:
Proctor's Telephone Number:
Proctor's Email Address:
Proctor's Fax Number:
Proctor's Mailing Address:

Note: Do not submit a Post Office Box address. The address must be a street number and name.

Please read the UTB/TSC Test Proctoring Policy, Guidelines, and Responsibilities for Online Students before you submit this form and type "I Agree" in the following text box.

Test Proctoring Agreement: