Distance Learning - Lewis-Clark State College

This is not a secure page. You may register online, fax, or mail this form to the address below. Thank you for assisting our students. All proctored exams must be administered in an educational or professional setting. A new form must be submitted for each test to be proctored. Please remit form one week prior to test date.

I have agreed to be this student's proctor.

Name of Student:

Course Title and No:
                                        Example: Bus 101-60

All the following information is necessary for us to verify your name and address. Please do not skip any fields.

Proctor Name:

Business Name:

Mailing Address:


Relationship to student:

Numbers of years known:

Daytime Phone:

Daytime Fax:

E-mail Address:

You may fax this form to:	208-792-2444

or

Mail it to:	Lewis-Clark State College Distance Learning 500 8th Avenue Lewiston, Idaho 83501

If you have any questions or concerns, please don't hesitate to call 800-879-0458 or e-mail Distance Learning.

Proctor Information Form