Midterm Examination Proctor Form This form is NOT for Final Exams

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Midterm Examination Proctor Form
This form is NOT for Final Exams! Contact the Registrar’s
Office ONLY regarding Final Exams.
Intersession/Spring Term 2016 Deadline: May 13th
Summer Term 2016 Deadline: July 15th
Students who have listed their exam centre as “other” need to ensure that this form arrives at the Centre
for Online Learning by the deadline – may be emailed, mailed, or faxed.
*Please fill out one form per course*
Student Information:
Name: ____________________________ Student Number: ___________________ Telephone:
(_____) __________________ Email Address: ____________________
Course: __________________________ Date of midterm: ____________________________
Please note: Confirmation of this form is not automatically sent. To confirm receipt, please include your name and course code(s) in an
email to [email protected]
Proctor Information:
Name: ___________________________ Business phone: (____) _______________
School/Business:____________________ Occupation: _______________________
Business Email: _____________________________________________________ PRINT CLEARLY
(Please note: gmail, hotmail, yahoo, etc. will not be accepted.) This is our preferred method for sending midterms. If a business email
is not available, please provide your business address.
Full Business Address: __________________________________________________
__________________________________________________________________
A full street address, postal code, and phone number are required for exams sent by a courier service.
I agree to follow the rules and regulations set for the writing of midterm exams. I have read the proctor
policies on page two. I certify that I am a suitable proctor for this student.
_________________________ ________
Proctor Signature
Date
_____________________________
Student Signature
Centre for Online Learning
Wilfrid Laurier University
75 University Ave W
Waterloo, ON N2L 3C5
Questions:
[email protected]
519.884.0710 ext 4881 or 3505
Fax: 519.884.6063
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Midterm Examination Proctor Policies
IMPORTANT: This Midterm Proctor Form is not valid for Final Examinations.
You must submit a Final Examinations Proctor Form to the Final Examinations Office.
Suitable Proctors:
 Faculty of a university or College
 Principal of a secondary or primary school
 University examination officer
 Embassy or Consulate
Responsibilities of the Student:
 Pay any fees charged by the proctor
 Pay any shipping costs to send the exam back to the Centre for Online Learning
 Write the midterm exam using the appointed proctor, on the scheduled date
 Return this form and the proctor’s proof of employment letter by the deadline to the address, fax
or, email listed below
Note: if you choose ‘other’ and require special accommodations, please contact the Accessible
Learning Centre.
Responsibilities of the Proctor:
 Submit a letter from your department chair, dean, principal, or Human Resource department as
proof of employment (without this, the exam will not be sent)
 Invigilate the exam on university, college, or school property on the scheduled date
Any changes being made must be approved by the Centre for Online Learning.
Centre for Online Learning
Wilfrid Laurier University
75 University Ave W
Waterloo, ON N2L 3C5
Questions:
[email protected]
519.884.0710 ext 4881
Fax: 519.884.6063
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