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Graduate School of Engineering Phone 617. 373. 2711 130 Snell Engineering Center Fax 617. 373. 2501 Northeastern University Web www. coe. neu. edu/gse 360 Huntington Avenue Boston Massachusetts 02115-5000 PROCTOR Application Form The proctor is responsible for administering exams to the students per the instructor s directions and in accordance with the Academic Honesty and Integrity Policy in order to maintain the security and integrity of the exam process. Please review the Online Course Policies and Procedures document for instructions for securing an acceptable proctor. Graduate School of Engineering Phone 617. 373. 2711 130 Snell Engineering Center Fax 617. 373. 2501 Northeastern University Web www. coe. neu. edu/gse 360 Huntington Avenue Boston Massachusetts 02115-5000 PROCTOR Application Form The proctor is responsible for administering exams to the students per the instructor s directions and in accordance with the Academic Honesty and Integrity Policy in order to maintain the security and integrity of the exam process. Please review the Online Course Policies and Procedures document for instructions for securing an acceptable proctor. The Proctor Application Form must be submitted No later than 2 weeks before first exam to allow for processing and approval of the selected Proctor. Once a proctor has been approved no changes will be made to the proctor s information as originally submitted* IF changes are needed i*e* new fax number different email address etc* the student will be required to submit a NEW Proctor Application Form as early as possible but no later than 72 hours prior to the exam* Instructions The Student must fill out the Proctor Application Form and give it to their proposed proctor. The proposed proctor MUST sign the form and have the student submit it to Brad C. Van Alfen via email b. vanalfen neu. edu. Please allow two weeks for processing* Student Name Please Print Clearly Student Email Course Number Instructor s Name Instructor Email Date s of Exam s Proctor s Name Company/Organization Business Address City State Zip Work Phone Email Alternate Phone i*e* Cell Relationship to Student I understand that it is my responsibility as proctor for the aforementioned student to assure the academic integrity of the exam process by following the explicit instructions provided to me by the instructor. I understand that failure to follow instructions may result in revocation of my proctor privilege and may adversely affect the student s grade for which I am serving as proctor. Proctor s Signature Date require the selection of a different proctor. This Proctor Agreement may be terminated at will by the proctor student or Northeastern University by providing written notification to all parties involved* Revised 4/16/2014. Graduate School of Engineering Phone 617. 373. 2711 130 Snell Engineering Center Fax 617. 373. 2501 Northeastern University Web www. coe. neu. edu/gse 360 Huntington Avenue Boston Massachusetts 02115-5000 PROCTOR Application Form The proctor is responsible for administering exams to the students per the instructor s directions and in accordance with the Academic Honesty and Integrity Policy in order to maintain the security and integrity of the exam process.

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