FY2025 MSVCC P&P (MELA Approved, Under APA, Submitted to SOS)

APPENDIX M: OFF-SITE/OUT-OF-STATE APPROVAL FORM

APPLICATION FOR OFF-CAMPUS TEST PROCTOR

Date: [Enter Date] Proctor’s Information:

• Name: [Enter Proctor’s Name] • Title: [Enter Title] • College/Affiliation: [Enter College/Affiliation] • Address: [Enter Address] • Phone Number: [Enter Phone Number] • Fax: [Enter Fax Number] • Email Address: [Enter Email Address] • Relationship to the Student: [Enter Relationship]

Agreement: I agree to serve as the proctor for the examination of the referenced student. I acknowledge that I have no relationship with the student outside that listed above. Proctor’s Signature: [Enter Signature] Date: [Enter Date] (Please attach a copy of your faculty/staff ID or statement of affiliation on organizational letterhead signed by an organization officer to this request.) Student’s Information: • Full Name: [Enter Full Name] • Address: [Enter Address] • City, State, Zip Code: [Enter City, State, Zip Code] • Phone Number: [Enter Phone Number] • Email: [Enter Email] • Course(s) Title (i.e., ACC1213 HO): [Enter Course Title] • Reason for not coming to campus: [Enter Reason] Submission Instructions: Return this form to the eLearning Office through email [email@example.com] or Fax [601- XXX-XXXX].

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