Miss. Code. tit. 9, pt. 8, app 9-8-M
APPLICATION FOR OFF-CAMPUS TEST PROCTOR
Date: [Enter Date]
Proctor's Information:
* Name: [Enter Proctor's Name]
* Title: [Enter Title]
* College/Affiliation: [Enter College/Affiliation]
* Address: [Enter Address]
* Phone Number: [Enter Phone Number]
* Fax: [Enter Fax Number]
* Email Address: [Enter Email Address]
* Relationship to the Student: [Enter Relationship]
Agreement:
I agree to serve as the proctor for the examination of the referenced student. I acknowledge that I have no relationship with the student outside that listed above.
Proctor's Signature: [Enter Signature]
Date: [Enter Date]
(Please attach a copy of your faculty/staff ID or statement of affiliation on organizational letterhead signed by an organization officer to this request.)
Student's Information:
* Full Name: [Enter Full Name]
* Address: [Enter Address]
* City, State, Zip Code: [Enter City, State, Zip Code]
* Phone Number: [Enter Phone Number]
* Email: [Enter Email]
* Course(s) Title (i.e., ACC1213 HO): [Enter Course Title]
* Reason for not coming to campus: [Enter Reason]
Submission Instructions:
Return this form to the eLearning Office through email [email@example.com] or Fax [601-XXX-XXXX].
Miss. Code. tit. 9, pt. 8, app 9-8-M