Proctor Request Form -- Student Resources -- Distance Learning -- Piedmont Technical College

Proctor Request Form

Testing Center schedules vary. Please contact your testing center for days and times. In addition, it is very important that when contacting your proctor/testing center that you schedule an appointment.

Student Information

*First Name MI *Last Name

Address

City State Zip *Phone

*PTC ID *E-mail

*Required fields

Required Proctor Information
The following is required information on your proctor. Please make sure that the proctor agrees to participate before sending us this information.

*First Name *Last Name

*College or University

Title or Duties

*Address

*City *State *Zip

*Phone Number *E-mail

*Fax Number

Course Information

*Course 1 for Proctoring: Course # *Title

*Instructor 1:

Course 2 for Proctoring: Course # Title

Instructor 2:

Course 3 for Proctoring: Course # Title

Instructor 3:

Course 4 for Proctoring: Course # Title

Instructor 4:

*Required fields

Regarding Security
Piedmont Technical College uses VeriSign® encryption technology to secure information that is transmitted via this form. To verify this information, please click on the VeriSign Secure Site symbol.