PROCTOR REQUEST FORM
Students who are registered with Pitzer Academic Support Services (PASS)
must complete and return this form FIVE DAYS before the exam date.
(To be completed by student registered with PASS)
STUDENT’S NAME: _______________________________________________________________________
ID #: ____________________ EMAIL: ______________________________________________________
CLASS (ex. PSYC010): _________________ REQUESTED TEST DATE: ___________ TIME: _________
STUDENT SIGNATURE: ______________________________________________ DATE: ______________
TEST INFORMATION:
(To be completed by Class Professor or Authorized Staff ONLY)
TESTING DATE (same day as class):
TEST 1 ___________ TEST 2 __________ TEST 3 __________ TEST 4 ___________
TEST TIME LENGTH (for class): _____________ AGREED START TIME FOR TEST: _____________
ALLOWANCES (Check all that apply):
__ Calculator __ Internet Access __ Open Book
__ Open Notes __ Time may be changed by Student __ Other (scratch paper, note cards etc.)
Additional instructions for exam: _________________________________________________________________
_____________________________________________________________________________________________
**PLEASE EMAIL EXAMS TWO DAYS BEFORE EXAM DATE TO: @academicsupport@pitzer.edu**
**OFFICE LOCATION FOR COMPLETED EXAM TO BE DELIVERED: _______________________**
APPROVED ACCOMMODATIONS (Check all that apply):
(To be completed by student registered with PASS)
___ INDIVIDUAL ROOM ___ READER ___ EXTENDED TIME (1.5x) or (2x)
___ SCRIBE ___ COMPUTER ___ OTHER: ___________________
**STUDENTS SHOULD REVIEW TESTING RULES BEHIND THIS FORM**
PROFESSOR CONTACT INFORMATION:
PROFESSOR NAME: ________________________________________ PHONE#: __________________________
SIGNATURE: _________________________________________________________________________________
EMAIL: ______________________________________________________________________________________
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