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Rev 10/07                                                                                1


                                 ELI Proctor Request

   Please allow up to 5 business days for processing of a proctor request. If you have
 questions, or to check the status of a request, call (703) 323-3347 or 1-888-4DL-NVCC
                          or email elicoursespecialists@nvcc.edu.

The acceptable reasons for requesting a proctor are:
   • You are located outside the Northern Virginia/Washington Metropolitan area.
   • You have a disability or illness which prevents you from traveling to a campus.
   • You are incarcerated.

If none of the above reasons applies to you, you will need to take your exams in an
NVCC campus testing center. You are responsible for transportation, childcare, and
work schedule adjustments.

Proctor requirements:
     • Must be a staff member at a college or university testing center, a full-time
        faculty member, or a professional librarian.
     • Cannot be a family member, employer, or someone with whom you work.
     • Cannot be an adjunct faculty member, teaching assistant, athletic coach, or
        student worker.
     • Military students may use an education or test control officer.
     • Disabled students should suggest an alternative proctor, preferably an educator,
        or contact ELI for help in identifying an appropriate proctor.
     • Incarcerated students should suggest an educator or counselor.
     • ELI must be able to verify your proctor’s employment and work title within an
        organization.

Students are responsible for securing their own proctor and paying any fees charged by
the proctor. ELI reserves the right to reject requests or proctors for any reason and
students will be contacted if a request has been denied. For all approved requests, exams
will be emailed or mailed to the proctor and students will receive an email confirmation
at their student email.vccs.edu address.

Directions:
STUDENTS: Complete Section 1 on the following page and give the form to your
proctor.

PROCTORS: Complete Section 2 and write or type the following statement, signed and
dated, on a copy of your organization’s letterhead: “I agree to serve as proctor for
(Student’s Name). I certify that the information I provided on the Proctor Request
Form is correct.”

Keep this page for your reference. Continue to proctor request form on page 2.
Rev 10/07                                                                          2


                              ELI Proctor Request Form

SECTION 1: STUDENT AND COURSE INFORMATION

My reason for requesting a proctor is (please check one):

___ I am located outside the Northern Virginia/Washington Metropolitan area.

___ I have a disability or illness which prevents me from traveling to a campus.
       (Please attach medical documentation.)

___I am incarcerated.

Student EMPLID: __________ Student’s Name:_________________________________

Address: _______________________City: _________ State: _____Zip Code: ________

Courses to be proctored: ___________________________________________________

Is this the first time you have requested proctored exams through ELI? ___Yes ___ No

VCCS Email Address: _______________________Telephone:_____________________

Your signature: ___________________________________Date:___________________

SECTION 2: PROCTOR INFORMATION

Proctor’s Name: ________________________________ Title:_____________________

Organization: __________________________________ Work phone: _______________

Address: _______________________City: _________ State: _____Zip Code: ________

Country if not in United States: ______________________________________________

Organizational Email Address: ______________________________________________
(Exams will not be sent to personal email addresses such as yahoo and hotmail.)

SEND THIS COMPLETED FORM, THE PROCTOR’S STATEMENT ON
LETTERHEAD, AND MEDICAL DOCUMENTATION IF APPROPRIATE TO:

Extended Learning Institute, 8333 Little River Turnpike, Annandale, Va. 22203,
Attn: Proctor Request

Requests may also be faxed to 703 323-3392, or scanned and emailed to
elicoursespecialists@nvcc.edu

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Ssdl proctor

  • 1. Rev 10/07 1 ELI Proctor Request Please allow up to 5 business days for processing of a proctor request. If you have questions, or to check the status of a request, call (703) 323-3347 or 1-888-4DL-NVCC or email elicoursespecialists@nvcc.edu. The acceptable reasons for requesting a proctor are: • You are located outside the Northern Virginia/Washington Metropolitan area. • You have a disability or illness which prevents you from traveling to a campus. • You are incarcerated. If none of the above reasons applies to you, you will need to take your exams in an NVCC campus testing center. You are responsible for transportation, childcare, and work schedule adjustments. Proctor requirements: • Must be a staff member at a college or university testing center, a full-time faculty member, or a professional librarian. • Cannot be a family member, employer, or someone with whom you work. • Cannot be an adjunct faculty member, teaching assistant, athletic coach, or student worker. • Military students may use an education or test control officer. • Disabled students should suggest an alternative proctor, preferably an educator, or contact ELI for help in identifying an appropriate proctor. • Incarcerated students should suggest an educator or counselor. • ELI must be able to verify your proctor’s employment and work title within an organization. Students are responsible for securing their own proctor and paying any fees charged by the proctor. ELI reserves the right to reject requests or proctors for any reason and students will be contacted if a request has been denied. For all approved requests, exams will be emailed or mailed to the proctor and students will receive an email confirmation at their student email.vccs.edu address. Directions: STUDENTS: Complete Section 1 on the following page and give the form to your proctor. PROCTORS: Complete Section 2 and write or type the following statement, signed and dated, on a copy of your organization’s letterhead: “I agree to serve as proctor for (Student’s Name). I certify that the information I provided on the Proctor Request Form is correct.” Keep this page for your reference. Continue to proctor request form on page 2.
  • 2. Rev 10/07 2 ELI Proctor Request Form SECTION 1: STUDENT AND COURSE INFORMATION My reason for requesting a proctor is (please check one): ___ I am located outside the Northern Virginia/Washington Metropolitan area. ___ I have a disability or illness which prevents me from traveling to a campus. (Please attach medical documentation.) ___I am incarcerated. Student EMPLID: __________ Student’s Name:_________________________________ Address: _______________________City: _________ State: _____Zip Code: ________ Courses to be proctored: ___________________________________________________ Is this the first time you have requested proctored exams through ELI? ___Yes ___ No VCCS Email Address: _______________________Telephone:_____________________ Your signature: ___________________________________Date:___________________ SECTION 2: PROCTOR INFORMATION Proctor’s Name: ________________________________ Title:_____________________ Organization: __________________________________ Work phone: _______________ Address: _______________________City: _________ State: _____Zip Code: ________ Country if not in United States: ______________________________________________ Organizational Email Address: ______________________________________________ (Exams will not be sent to personal email addresses such as yahoo and hotmail.) SEND THIS COMPLETED FORM, THE PROCTOR’S STATEMENT ON LETTERHEAD, AND MEDICAL DOCUMENTATION IF APPROPRIATE TO: Extended Learning Institute, 8333 Little River Turnpike, Annandale, Va. 22203, Attn: Proctor Request Requests may also be faxed to 703 323-3392, or scanned and emailed to elicoursespecialists@nvcc.edu