Student Remote Proctor Now
Request & Agreement Form
Jackson State University
JSU E-mail address
Student name
Contact Number
I am requesting to complete the exam listed below via Remote Proctor Now. I have initialed
beside each of the following statements as an indication of my understanding and acceptance of
my responsibilities in ensuring:
I agree to work in a secure and appropriate environment for testing.
I will provide proof of identity using an
official university or government provided
identification (e.g. college/university ID, drivers’ license).
I understand that a video and written report will be provided to the instructor or test
administrator of all testing improprieties observed, including the identity of the
student(s) involved.
I will abide by the instructions provided by the instructor or test administrator for taking the exam.
I w
t use
y supplemental materials during the exam, unless authorized to do
he test administrator/instructor.
I will retain confidentiali
ty of this exam from all persons except the test administrator/
Student signature
Enter Exam Title
I will ensure that the integrity of the exam is not compromised.
Course Name (e.g. ENG-104-100)
Instructor Name
Instructor Email
Comments or Information Request
Exam Date
The student must return this completed form to Phone:(601) 979-0779 or
Fax: (601) 979-9331.