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Outside Proctor Request Form

Before filling out this form please review the Guidelines for Setting up a Proctor

General Information ( * Denotes a required field)

*Are you a student from an outside institution, not LCC, and need LCC to proctor for you?     Yes No

*Have we proctored for you before?  Yes No

If yes, when and for what institution?

*Do you know any of the staff at our testing facility on a personal basis?
Yes No

If Yes, please explain:

*Please complete the following information.(Be as specific as is necessary to avoid delays in your request):

Student Information

*Student Name      

*Birth Date                 

*Student Telephone     

*Student Address      

*Student City  

*Student State  

Country, State or Province:  . 

*Student Zip/Postal code    

 *Email Address            

*Verify Email Address    

Educational Institution Information

*Contact person at institution:      

*Contact person telephone:   

Contact Person Fax: 

*Institution Name:      

Institution Address: 

Institution City: 

Institution State: 

Country, State or Province:

Educational Institution Zip/Postal code: 

*Contact Person Email Address:

*Verify Contact Person Email Address:

Do you require special testing accommodations, if so please explain. (Please note that documentation may need to be provided for your request)

Other Comments


The Online Testing Support Office will not process your request, unless the form is complete.

The Online Testing Support Office requires seven to ten businesses days to process a request.

For additional information, please visit our website at

If you have any questions or concerns, please contact Mark Polzin at:
517-267-5513 or by email at


Assessment Center at Lansing Community College

Assessment Center
Course Testing - TLC 104

Placement Testing - GB StarZone
Phone: (517) 267-5500
Additional contact information »

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