General Information ( * Denotes a required field)

*Are you a student from an outside institution, not LCC, and need LCC to proctor for you?     Yes No

*Have we proctored for you before?  Yes No

If yes, when and for what institution?

*Do you know any of the staff at our testing facility on a personal basis?    Yes No

If Yes, please explain:

*Please complete the following information.(Be as specific as is necessary to avoid delays in your request):

1. List the title of each course that you need proctored: 2. List the name of the test(s) that you need proctored: 3. List the number tests you need proctored: 4. List the format of the test(s), pencil, paper, or online:

Student Information

*Student Name      

*Student #                    SS#'s are not accepted.

*Birth Date      January Febuary March April May June July August September October November December       1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31      

*Student Telephone     

*Student Address      

*Student City  

*Student State   International Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Jersey New York New Hampshire New Mexico North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Wisconsin West Virginia Wyoming

Note: If you are using an international address please select "International" as your Student State. Then type in your Country, State or Province below.

Country, State or Province:  . 

*Student Zip/Postal code    

 *Email Address            

*Verify Email Address    

*Semester Attending:     Spring 2012 Summer 2012

Educational Institution Information

*Contact person at institution:      

*Contact person telephone:   

Contact Person Fax: 

*Institution Name:      

Institution Address: 

Institution City: 

Institution State:  International Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Jersey New York New Hampshire New Mexico North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Wisconsin West Virginia Wyoming

Note: If you are using an international address please select "International" as your Institution State. Then type in your Country, State or Province below.

Country, State or Province:

Educational Institution Zip/Postal code: 

*Contact Person Email Address:
 

*Verify Contact Person Email Address:
 

Do you require special testing accommodations, if so please explain. (Please note that documentation may need to be provided for your request)

Other Comments

ATTENTION:

The Online Testing Support Office will not process your request, unless the form is complete.

The Online Testing Support Office requires seven to ten businesses days to process a request.

For additional information, please visit our website at www.lcc.edu/assessment/

If you have any questions or concerns, please contact Patricia (Torey) Griffith at: 1-800-644-4522 x5519 or by email at lcc_proctoringservices@lcc.edu