Mississippi Administrative Code
Title 9 - Education- Mississippi Community College Board
Part 8 - Policies And Procedures Manual
Appendix 9-8-M - Off-Site/Out-Of-State Approval Form

Application for Off-Campus Test Proctor

Date: ___________

Proctor's Name: __________________________

Title: __________________________

Institution/Affiliation: __________________________

Address: __________________________

_______________________________

Phone Number: __________________________ Fax: __________________________

Email Address: __________________________

Relationship to the Student: __________________________

I agree to serve as the proctor for examination of the referenced student. I acknowledge that I have no relationship with the student outside that listed above.

Proctor's Signature:____________________ 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 Full Name: __________________________

Address: __________________________

City, State, Zip Code: __________________________

Phone Number:___________________ Email: ___________________

Course(s) Title (i.e. ACC1213 HO): __________________________

Reason for not coming to campus: __________________________

Return this form to the eLearning Office through email abc@test.edu or Fax 601-XXX-XXXX.