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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