Student Information:
*Name:
Student Name is required.
*Address:
Address is Required
*City, ST Zip:
City, ST Zip are required
*Phone Number:
Student Phone # is required.
*E-mail Address:
Email Address is required
You must enter a valid email address
Course Information:
*Course Number:
Course Number is required
*Section:
Section is required
*Instructor:
Instructor is required
Course Number:
Section:
Instructor:
Course Number:
Section:
Instructor:
Course Number:
Section:
Instructor:
Course Number:
Section:
Instructor:
Proctor Information:
*Name:
Proctor Name is required
*Relationship to Student:
Relationship to Student is required
*Title:
Title is required
*Work Phone:
Proctor Work Phone is required
*Address:
Proctor Address is required
*Work E-mail:
Proctor Email Address is required
You must enter a valid email address
*City, ST Zip Proctor City, ST Zip is required
*Work FAX:
Work FAX Number is required
NOTE: An examination proctor is a responsible individual who is NOT a relative, spouse/partner, friend, neighbor, coach, co-worker/business associate, direct supervisor, or resides in the same household of the student.
Organization Type:
I certify that by entering my name and today's date below, I am the officially enrolled GCSC student identified on this examination. I attest that all proctor information contained on this form is correct and conforms to the guidelines for suitable proctors. I understand that any deliberate misstatement of fact may result in my losing the privilege of using GCSC proctoring and a grade of "F" being assigned for any and all courses-past and present-in which examinations were taken under such misstatement. I acknowledge that it is my responsibility to locate a proctor, schedule my exam appointments, and pay for any proctoring service fees required.
Student Signature:
Signature is required Date:
Date is required
