Proctor Request Form for LCC Online Learning Students

All LCC online learning students who reside 60 miles from LCC'S main campus Assessment Center are eligible to test off-campus.

Students who request to test at the Livingston County Center, and do not meet the 60-mile requirement will be charged a $15 per test fee.

Please verify with your instructor to determine if your exams must be proctored.

Please go to www.lcc.edu/assessment/off_campus/FAQ.aspx for additional information.

Student Information ( * Denotes a required field)

Are you a current LCC online student who is requesting to test off-campus? Yes No

*Student Name

*Student # SS#'s are not accepted.

*Birth Date

*Student Telephone

*Student Address

*Student City

*Student State

Note: If you are using an international address please select "International" as your Student State. Then type in your Country, State or Province below.

Country, State or Province: .

*Student Zip/Postal code

*Email Address

*Verify Email Address

*Semester Attending:

Please list all on-line courses and instructors that you will be enrolled in this semester.

*Courses

*Instructors

Proctor Information

*Proctor Name (What's this?)

*Proctor Location

*Proctor Address

*Proctor City

*Proctor State

Note: If you are using an international address please select "International" as your Proctor State. Then type in your Country, State or Province below.

Country, State or Province: .

*Proctor Zip/Postal code

*Proctor Email

*Verify Proctor Email

*Proctor Telephone

Proctor Fax

*Have you used this proctor location in previous semesters? If yes, what semester?

If your proctor charges a fee please list their fee in the box below

*Do you know the proctor on a personal or professional basis?

Yes No

If yes, Please explain.

*Please provide the title of your online learning course(s)

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

Other Comments

ATTENTION:

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. You will receive an email notification once your request is processed.

For additional information, please visit our website at www.lcc.edu/assessment/

If you have any questions or concerns, please contact our office at:

1-800-644-4522 x5503 or by email at lcc_online_testing@lcc.edu

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Proctor Request Form for LCC Online Learning Students