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E X A M P R O C T O R I N S T R U C T I O N F O R M
P r o c t o r N a m e : F O R M T E X T D a t e : F O R M T E X T
S t u d e n t N a m e : F O R M T E X T
C o u r s e T i t l e : F O R M T E X T E x a m : F O R M T E X T
I n s t r u c t o r : F O R M T E X T P h o n e : F O R M T E X T E m a i l : F O R M T E X T
1 . T h i s e x a m c a n n o t b e c o p i e d o r s h o w n t o a n y o t h e r s t u d e n t .
2 . T h e s t u d e n t s h o u l d b e p r o v i d e d w i t h a s p a c e i n w h i c h t o t a k e t h e e x a m , w i t h a m i n i m u m o f d i s t r a c t i o n s a n d n o i n t e r r u p t i o n s .
3 . W h e n t h e e x a m has been completed, fax exam answer sheets and signed proctor instruction form to (541) 463-3974. Please mail the paper copy of the exam and answer sheet to: Lane Community College Distance Learning, 4000 E. 30th Avenue, Eugene OR 97405. Please do NOT give the completed exam to the student or allow them to make a copy of the exam.
SPECIFIC INSTRUCTIONS FOR THIS EXAM:
Time Limit: Yes FORMCHECKBOX No FORMCHECKBOX If yes, how long FORMTEXT
N o t e s : Y e s F O R M C H E C K B O X N o F O R M C H E C K B O X
B o o k s : Y e s F O R M C H E C K B O X N o F O R M C H E C K B O X
D i c t i o n a r y : Y e s F O R M C H E C K B O X N o F O R M C H E C K B O X
C a l c u l a t o r : Y e s F O R M C H E C K B O X N o F O R M C H E C K B O X
E x t r a p a p e r : Y e s F O R M C H E C K B O X N o F O R M C H E C K B O X
O t h e r i n s t r u c t i o n s : F O R M T E X T
P l e a s e m a r k a l l a n s w e r s o n t h e :
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T O B E C O M P L E T E D B Y T H E P R O C T O R :
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F O R M C H E C K B O X T h e s t u d e n t n a m e d a b o v e i s p e r s o n a l l y k n o w n t o m e .
F O R M C H E C K B O X T h e s t u d e n t n a m e d a b o v e h a s p r e s e n t e d i d e n t i f i c a t i o n t o v e r i f y h i s / h e r i d e n t i t y .
D a t e e x a m g i v e n : F O R M T E X T
T i m e g i v e n : F r o m : F O R M T E X T a m / p m T o : F O R M T E X T a m / p m
P r o c t o r s S i g n a t u r e : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
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