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TTU Math Proctor Approval Form I To be completed by Student Student Contact Information Name Email Phone Semester and Year Online Math Course Name Course Number The proctoring service or individual that I am submitting for approval is check all that apply An education o cer or librarian at a community college university elementary or secondary school A testing administrator at a college university or private testing service A military Learning Center or military o cer of a higher rank the above-named student Fill in the proctors or testing center directors name and organization e.g. City of Lubbock Public Library Houston City Community College Sylvan Learning Center etc. Proctor/Testing Center Director Name Organization Name I the student named above agree to the following a to locate a proctor or testing center and set up an appointment for my course exam s according to published dates b to arrange for fee payment for the proctoring services if any. Signature II Date Area Code/ Phone Number Address City/State/Zip Email Address YES NO Fees are assessed to students for services associated with proctored testing. I certify that for the student named above 1 I do not have any con ict of interest 2 I agree to serve as an exam proctor subject to the testing guidelines of the TTU Department of Mathematics and Statistics. Signature II Date Area Code/ Phone Number Address City/State/Zip Email Address YES NO Fees are assessed to students for services associated with proctored testing. I certify that for the student named above 1 I do not have any con ict of interest 2 I agree to serve as an exam proctor subject to the testing guidelines of the TTU Department of Mathematics and Statistics.

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