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CERTIFICATE OF TEST PROCTOR
Proctor Verification
Submitting this completed form will allow to release the exam to the proctor via fax.
(Name of school)
Nevada Administrative Code (NAC) 645.412 requires that a student who enrolls in a distance education program must pass a
proctored, closed-book final examination. The proctor (someone over 18 who is not related to the student / see section 1 below) must
complete this form and fax the completed form to .
(Name of school) (Phone Number)
All proctor signatures are required to be notarized. This insures the proctor is a real and valid person. All sections of this form must
be completed for a test to be sent to the proctor.
Instructions to proctor: Complete this form then email or fax the form
will email or fax the exam to be proctored
(Name of school)
Name of the course taken
(Use the students receipt or the title of the workbooks)
Name of the student taking the test
The proctor certifies that:
1. I am a disinterested third party in the administration of this examination. I am not related by blood, marriage or any other
relationship to the examinee that would influence me from properly administering the examination. I am not a real estate
licensee nor am I affiliated with a real estate brokerage firm.
2. The student taking the exam will show me positive photo identification prior to taking and completing the examination.
3. The enclosed examination will be administered under my supervision on the following date: ___________________.
4. The student received no assistance in taking the examination.
5. The test should be sent to my attention at: Fax ____________ or Email __________________________________ .
6. may contact me with questions via phone at the following number: _________________.
(Name of school)
7. I will not permit the examination to be compromised, copied, or recorded in any way or by any method.
8. After examination is administered, I will fax/email completed examination to your school.
Printed Name of Proctor Signature of Proctor
Address City State Zip
State of _______________ } (Notary Seal)
}SS
County of _______________ }
Subscribed and sworn to before me this _____ day of _______________, 20____.
________________________________ My appointment expires on _______________.
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signature
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