CIDDE Academic Testing - Proctor Testing

	University of Pittsburgh Center for Instructional Development & Distance Education
	Testing Services, PittOnline Program 824 Alumni Hall 4227 Fifth Avenue Pittsburgh, PA 15260 Phone: 412-624-7215; Fax: 412-624-6059
Application for Proctor Testing (to be completed and submitted online by the student) To apply for proctor testing, take this proctor application to a library, community college or a college/university in your area. You should have the proctor complete and sign the application and attach a business card. To expedite the process, fax the completd proctor application (412-624-6059). Please note that if there is a service fee, it is the sole responsibility of the student.

Name:
E-mail:
PeopleSoft Number:
Street Address:
City/State/Zip:
Daytime Phone:	Evening Phone:
Reason for requesting proctor testing:

I certify that the above information is correct and that I have read and understand the Student Testing Regulations on the reverse.

_________________________________________________________
(signature & date required if returning by mail)