Proctor Data Form
FAMU-FSU College of Engineering
MS Online Program Director
2525 Pottsdamer St, Room 229
Tallahassee, FL 32310-6046
To the student:

Please print out this form. Also prepare a stamped envelope to the address shown to the right, and give both to your proctor.

To the proctor:

This form will allow you to act as a proctor for the exams taken by the student named below. Duties include ensuring that the test is taken during the correct times according to the instructions of the instructor, using only the allowed information sources. We ask that you also keep a copy of each exam until the graded exam has been returned. Please fill out the information below, writing clearly. For all questions, please contact the Web Education Director.

Student's name: ______________________  Soc. Sec. Number: ______________________
Proctor's name: ______________________  E-mail address: ______________________
Telephone number: ______________________  FAX number: ______________________
Proctor's employer: ______________________  Proctor's position: ______________________
Exam location: _ At proctor's employer
_ See comments below		  Employer's
 Permission [1]: 		_ Not applicable
_ Implicit consent
_ Explicit consent
_ See comments below
Employer address [2]:
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________		 UPS address if different [2]:
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________
Relationships of proctor to student [3] and other comments:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
  1. Proctoring during employment times or using the employers facilities must be with the consent of the proctor's employer.
  2. All examinations will be sent to one of the two addresses and should be kept sealed until the time of the exam.
  3. Please describe any relevant relationships between the proctor and the student. Include any information that might reasonably be taken to affect the objectivity of the proctor (family relationships, close personal friend, financial obligations, etcetera). Clarify as needed.

____________________________________________
Proctor's Signature 		  ____________________________
Date