Student Information

Student Name:  

PSU ID:  

Phone:  

E-mail:  

Instructor Information

Instructor Name:  

Course Number and Section (i.e. SPAN 002, section 3)  

Proctor Information (Relatives and friends are not suitable proctors)

Has this person previously served as a proctor?  

Yes
No

Name:  

Position/Title:  

Business/Library/School Name:  

Business/Library/School Website:

Business Address

Street:  

City:  

State:  

Zip:  

Business Phone Number:   Area Code and Phone Number

Email Address:   Please note: The proctor’s e-mail address MUST be a business e-mail address.

Verify Proctor Information Upload a document that verifies your proctor's identity (letter, letterhead, etc.)

Is this person able to proctor online exams?  

Yes
No

Is this person a friend or relative?   Please note: Relatives and friends are not suitable proctors, and the use of an unauthorized proctor is considered an act of academic dishonesty

Yes
No

By agreeing, I certify that the enclosed information is true and legitimate, and complies with the corresponding guidelines outlined by course and University policies, and that the proctor is not a relative or friend. Failure to abide by course and University policies on academic integrity will be reported to the College of the Liberal Arts, and academic sanctions may fall upon me.

Please indicate your agreement with the above statement.  

I agree

Please type your full name as your electronic signature. By typing your name on this agreement, you agree to abide by the letter and spirit of this policy.