Proctor Identification and Approval Request
Jackson State University
Student’s Name J#
Course Prefix and Number
(ex. ENG 104)
Contact Number
CRN (ex. 92155)
The student named above is requesting approval of the following proctor to supervise testing.
Proctoring Site _______________________________________________________________________________________
Name of Organization
________________________________ _________ ______________ _______ - ________________
City State Zip Code
Test Date Test Time
Proctor Name Proctor’s Relationship to student
Place of Employment Position
Office phone # Fax#
E-mail address Alternate Phone#
Mailing Address _____________________________________________________________________________________
Street Address or P. O. Box
___________________________________ _________ ____________________ - ______________
City State Zip Code
Proctor’s Signature Date
Student’s Signature Date
Approved by Title Date
The student must return this completed form to Phone:
(601) 979-0779 or Fax: (601) 979-9331.
JSU Email