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Managing External Relations - Disaster Management Center ...

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<strong>Disaster</strong> <strong>Management</strong> <strong>Center</strong><br />

University of Wisconsin-Madison<br />

Examination Request Form<br />

This exam must be proctored (supervised) just as it would be for a course taken on campus. Generally, proctors do<br />

not charge for this service. In all cases the academic department offering the course must approve the choice of<br />

proctor. Qualified proctors include university or college registrars, deans or counselors or professors; high school<br />

principals or counselors; directors of educational services at universities, other educational organizations,<br />

correctional institutions or the armed services; certified librarians in a supervisory position; or the delegated officials<br />

at university testing centers. Students residing outside of the United States may also request, as their proctor, a<br />

local director of educational services or an officer of the United States embassy or consulate. Please copy this<br />

form as needed.<br />

Date Submitted ________________________________________________________________<br />

Course Title ________________________________________________________________<br />

Student Information:<br />

Name ________________________________________________________________<br />

Mailing Address ________________________________________________________________<br />

Proctor Information:<br />

________________________________________________________________<br />

________________________________________________________________<br />

Name ________________________________________________________________<br />

Title ________________________________________________________________<br />

Organization ________________________________________________________________<br />

Complete Mailing Address (Please provide street address, in case courier service is used.)<br />

________________________________________________________________<br />

________________________________________________________________<br />

________________________________________________________________<br />

Phone Number OR<br />

Email Address ________________________________________________________________<br />

Please return this form by mail or fax, or send the information via e-mail to:<br />

University of Wisconsin–<strong>Disaster</strong> <strong>Management</strong> <strong>Center</strong><br />

432 Lake Street<br />

Madison, Wisconsin 53706, USA<br />

Fax: 1-608-263-3160 E-mail: dmc@engr.wisc.edu

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