Please complete one form for each course you are taking that requires proctored testing.

This form should be completed, the signature of the proctor notarized, and sent to the following address no later than 10 days after the beginning of the course:

DALLAS TeleCollege
LCET
9596 Walnut Street
Dallas, Texas 75243-2112

If completing by hand, please print clearly.

Student Name: Day Phone#:
Address: Eve. Phone#:
City, State, Zip:
E-mail:
Student ID#:
Course number: Section: Title:
Instructor Name:

Special Testing Equipment or Conditions Required:

Equipment or Condition Required I will/will not be able to supply.____________________
Equipment:____________________ I will/will not be able to supply.____________________

Number of Proctored Tests in Course:______

To be completed by Proctor Nominee:

Name:  
Title:  
Place of Employment:  
Office Address
(& Zip):		  
Office Phone:  
Fax #:  
E-mail Address:  

I am able to receive and return testing materials by: (check all that apply)

____ e-mail: through an institutional server
  regular mail/UPS: using official letterhead
  fax: using official letterhead

I will agree to serve as the proctor for the student identified above. As test proctor, I will receive, administer and return all tests according to the directions provided to me. I will certify that the student completed the test according to the directions provided. The tests I agree to proctor are:

___ all course tests
___ first course test only
___ other (please specify)

Signature __________________________ Date ______

Notary SIG/Seal _________

_____ I am not related to this person.

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