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
Proctor Application (To be completed by Proctor)
Student Name:
PeopleSoft Number:
Proctor Name:
Proctor Relationship to Student:
Street Address:
City/State/Zip:
Day Phone:
Current Employer:
Position/Title:
Employer Address:
City/State/Zip:
Day Phone:
Will the exam(s) be administered at the employer address? _____ Yes _____ No
If no, please state specific location and address where exam(s) will be administered.
I agree to administer examinations for the University of Pittsburgh's Pitt Online Program. I agree to provide adequate examination security as long as these examinations remain in my care and to abide by the testing regulations listed. I understand that verification of my employment, position, and/or credentials may be required. (Please attach business card and sign below.) ___________________________________ (signature & date required) CIDDE USE ONLY Date received in office:___________________ Date exams were mailed:____________________ Course(s):_____________________________________________________________ Term:__________________ Approved ______ Not approved ______ _________________________________________________________ (signature & date)