Genesee Community College
EXAM PROCTOR REQUEST FORM
A hard copy of the completed form can be returned to Professor Mead by
scanning the form as a .pdf file and sending as an email attachment at
kjmead@genesee.edu.
STUDENT NAME: __________________________________________
SEMESTER:
Spring
Summer
Fall
YEAR: __________________
PROCTOR NAME: __________________________________________
PROCTOR’S EMPLOYER: ______________________________________
PROCTOR’S POSITION / TITLE: _________________________________
MAILING ADDRESS:
______________________________________
______________________________________
WORK PHONE NUMBER: ______________________________________
EMAIL ADDRESS: ____________________________________________
Sign below to verify your agreement to serve as proctor:
As proctor, I agree to be available to the student at a mutually agreed upon
time for exams.
Signed:___________________________________
Date: ____________
Thank you for helping out this semester!
Regards,
Ken Mead
Professor of Mathematics and Computer Information Systems
Genesee Community College