FLORIDA COMMUNITY COLLEGE AT JACKSONVILLE

Distance Learning Testing Center

Remote Test Site Proctor Approval Form

Notes:

1. This form to be completed only for those students outside of the Jacksonville/First Coast area.
2. Students in the Jacksonville, Fl. area should call 632-5020 or e-mail assessme@fccj.edu for arranging local testing.
3. The remote site must be a college, university or military ESO. No other locations will be approved.
4. Remote proctors must be affiliated with the school’s testing program and authorized to administer exams on behalf of the institution.
5. Military test proctors must be appointed or assigned to the Educational Services Office.
6. The student is responsible for any fees charged by the remote test site.

Student Name: _______________________________________________________________
Student SSN: ________________________________________________________________
Daytime Telephone Number: __________________Email Address:_______________________
Is this a request for the College Placement Test? ________YES _______NO
Classes registered for:
Course Name: ________________________Instructor: __________________Reference Number:_______________

Course Name: ________________________Instructor: __________________Reference Number:_______________

Course Name: ________________________Instructor: __________________Reference Number:_______________

Course Name: ________________________Instructor: __________________Reference Number:_______________

Remote Test Site Information
Remote Test Site:_____________________________________________________________
Proctor Name:_______________________________________________________________
Proctor Title:________________________________________________________________
Mailing Address:_____________________________________________________________
__________________________________________________________________________
City/State/Zip Code:__________________________________________________________
Telephone Number:___________________________________________________________
Proctor Email Address:________________________________________________________
School Web Address:_________________________________________________________

I certify that I will administer exams under conditions requested by Florida Community College at Jacksonville.

_______________________________ _______________________________
Proctor Name                                           Proctor Signature

Send completed forms to:

Carl Jowers
Open Campus Assessment Center
Florida Community College at Jacksonville
601 W. State Street
Jacksonville, Fl. 32202

Office: 904-632-5020

Fax: 904-633-8445

Email: assessme@fccj.edu.