Non-BRCC Instructor - Proctor Request Form
This form must be completed by an instructor or other authorized personnel.
Instructor Name
Please give us your name.
Your answer
Student Name
Please give us your student's name.
Your answer
Course Name
In which course is your student enrolled?
Your answer
Phone Number
Please provide us with a phone number where you can be reached.
Your answer
Email Address
Please provide us with an email address where we may contact you.
Your answer
Test Type
Is this a web-based test to be unlocked with a password or will you provide us with a paper test?
Allowed Materials
What materials are allowed for this exam?
Opening Test Date
When does your test open?
MM
/
DD
Closing Test Date
When does your test close?
MM
/
DD
Signature
Please type your name as, a digital signature, certifying that the above information is correct.
Your answer
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