Gannon University Proctor Certification Form

Gannon University Proctor Certification Form

Thank you for agreeing to supervise a Gannon Distance Education examination. Please take a few minutes to complete this certification form. After completing this process, you will be notified by Distance Education concerning your certification status within two business days by e-mail. This certification will be valid for two years, at which point you will need to fill out a new form to remain a certified proctor with our office.

This form may NOT be filled out by anyone other than the person applying to be certified as a proctor. Students MAY NOT fill out this form for their proctor. If this is done the form will become invalid and the proctor will immediately be rejected

PART 1: STUDENT INFORMATION
First Name
Last Name
E-mail Address

Part 2: PROCTOR INFORMATION

I certify that I will be filling out this form for myself to become a certified proctor with UVU Distance Education and for no one else. I also certify that all information give will be my own, and I will not give any false information to the best of my knowledge.

Proctors may NOT be any of the following:

• Relative or friend with whom you have a personal relationship outside of Gannon University
• Employer or Supervisor
• Tutor
• Athletic Coach, including assistant coaches
• Current Gannon student

I certify that none of the above applies to me

I certify that I am NOT an athletic coach, athletic administrator, or athletic academic counselor. Whether it be part-time or full-time, I am not in any of these positions.

Please select your title from the list below: (only those who currently hold one of the titles below are eligible to be proctors)

• Full-time school or public librarian
• Full-time teacher
• Guidance counselor/counseling staff
• School superintendent, principal, vice principal or other administrator
• Embassy education officer
• Military base education officer or superior officer
• Firechief or captain
• Local college/professional testing center staff or administration

Proctor Contact Information

First Name

• *Address:
• *City:
• *State / Province Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Aguascalientes Baja California Norte Baja California Sur Chihuahua Colima Campeche Coahuila Chiapa Distrito Durango Guerrero Guanajuato Hidalgo Jalisco Michoacan Morelos Nayarit Nuevo Leon Oaxaca Puebla Quintana Roo Queretaro Sinaloa San Luis Potosi Sonora Tabasco Tlaxcala Tamaulipas Veracruz Yucatan Zacatecas N/A
• *Postal Code:
• *Phone number:
• Fax number:

Proctoring Location

Exams must be administered at your school, military base or educational facility - never at your home or the student's home.