DSU Extended Programs
Proctor Agreement for Distance Courses

~ Not Using BOR Proctoring Services

Student Information                                                                            

Note:  red star * indicates required field

First Name:  *
Last Name:   *
Student/Colleague ID #:  *
Phone #:   * (xxx-xxx-xxxx)
University Issued Email Address:   *  valid
Semester:     Fall    Spring   Summer*
Proctor Information  
Proctor First Name:  *
 Proctor Last Name:   *
Relationship to Student:  *
Job Position:   *
Employed by:   *


Mailing Address,

City, State Zip:

Professional Email Address:   no Gmail, Yahoo, Hotmail, etc.*
Business Fax Number:  
Business Telephone:   * (xxx-xxx-xxxx)
      I have read and understand the Proctor Guidelines and Policies. *

2012 DSU Extended Programs. All Right Reserved

Last Update: September 20, 2013