Proctor Agreement
Course Title _________________________________________
Student Name ___________________________________
Proctor Name:___________________________________
Proctor's Job Title:_____________________________
Proctor's Employer:_________________________________
Proctor's work unit/department:__________________________________
Business Street Address ______________________________________
City _______________________________ State _______________ Zip _______________________
Business Phone ________________________ Fax __________________________
Proctor E-Mail address:_________________________________________________
What is your relationship to the student?__________________________________________________________
Location that proctoring will occur - please be as specific as possible.
(Examples: Newport High School Guidance Office, proctor's home, Des Moines Public Library, Sac County Extension Office):
__________________________________________________________________________________________
List of times you could be contacted should the need arise:
By signing below I agree to proctor the student named above. This means I will monitor the student during test taking making sure no notes or textbooks are used.
Date __________________ Proctor Signature ___________________________________________