Note: Illinois students should take their exams at one of 40 student support centers participating in the Illinois Virtual Campus. A listing of these sites is available at http://www.ivc.illinois.edu/student/. Out of state students or Illinois students unable to use an IVC support center must make special arrangements. All students requiring proctored exams need to complete the following form and mail to their instructor to initiate the proctored exam procedures.

Online Proctored Exam Request Form
Please print from the web and mail or fax to the instructor.

Contacting the institution and proctor for the exam and any costs associate with the proctored exam, either site or proctor, are the student’s responsibility. Appointment dates and times for examination are at the convenience of the proctor. Please complete and sign this request and mail to your classroom instructor. Your instructor must receive this form two weeks prior to the exam date. Please type or print carefully.


Today’s date _____________________ Date of exam __________________________________________


Student’s name _____________________________________________________

Course ____________________________________________________________
(Course number and title)

Student’s address___________________________________________________________________

City _______________________________________________________State ________ Zip Code__________

Student’s email address_________________________________________________________________________
(please type or print in carefully)


Institution for proctored exam. (Note: Other sites may be proposed to the instructor if none of those listed below are available. Contact the instructor to discuss alternatives before submitting this form. Students should be aware that some locations may charge a fee. Students are responsible for payment of any fees associated with the exam site.)

___ Illinois Virtual Campus facilities at Illinois Community Colleges
___ University of Illinois at Urbana-Champaign
___ University of Illinois at Chicago
___ University of Illinois at Springfield
___ Accredited institution of higher learning (i.e., college, community college, or university)
       (Name of above institution)_____________________________________________________
____ Office of the regional superintendent of schools
____ Office of the superintendent of public or parochial school districts
____ Academic or public library Academic or public library
____ Educational Offices of the United States Armed Services

Proctor for the exam. (Note: Other proctors may be proposed to the instructor if none of those listed below are available. Contact the instructor to discuss alternatives before submitting this form.)

____ Exam center personnel of accredited institutions of higher learning
____ Regional superintendent office personnel
____ Superintendent of public or parochial school districts personnel
____ Head librarian at major public libraries
____ Dean, academic department head, extension or correspondence administrator, registrar, or
official testing administrator of an accredited college or university 

Proctor Identification and Contact Information

Proctor’s name___________________________________________________________________________

Proctor’s official title _____________________________________________________________

Proctor’s institution _______________________________________________________________

Proctor’s street address _____________________________________________________________________

City __________________________________________________________State _______ Zip __________

Proctor’s email address ____________________________________________________________________

Proctor’s phone number (including area code)______________________________________________