Gateway

Gateway Community College
Test Proctor Form for Online Distance Learning

This form is used to register a Proctor to administer an Online Distance Learning course exam for students who live outside Maricopa county and cannot come to the ICT Lab (Room MA2122 Main Building) for testing.

A proctor is an individual who agrees to receive the tests from the student's instructor, administer them in an approved environment and return them to the instructor. The proctor must verify that the student completed the test according to the specific directions of the instructor. Examples of individuals who may be eligible to serve as proctors are:
 - College or university personnel such as deans, department chairs, professors, librarians, or testing center personnel.
 - Public or private school personnel such as superintendents, principals, guidance counselors, teachers.
 - Other personnel such as civil service examiners, military officers.
Relatives and friends, regardless of their position, are not permitted to act as proctors.

The student is responsible for sending this completed form to the ICT Lab prior to the course end date.
The Proctor form may be --

mailed:
   ICT Computer Lab
   Gateway Community College
   108 N. 40th Street
   Phoenix, AZ 85034

faxed:
   (602) 286-8571

Gateway Community College Test Proctor Form

Course Title:
Course Section
End Date
Name of Instructor:
Name of Student:
Student’s Address:
City 
State and Zip 
Phone Number:
Email Address:
Reason for Request:
 
Name of Proctor:
Title of Person or official capacity of proctor:
eMail (for receiving test materials):
Address of proposed proctor (for mailing of any test materials):
City 
State and Zip 
Fax # (for faxing test materials):

This section to be completed by the proctor:

I attest that I can and will provide an appropriately secure environment for this student to complete the designated examinations for this course and will abide by the instructions of the instructor. I further attest that I will retain the confidentiality of this examination from all persons except the instructor and will return the examination strictly according to the instructions provided by the instructor.

Signature:
Date:
Daytime telephone number:

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