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OFF-CAMPUS EXAM REQUEST FORM

You must complete a separate form for each online course you are enrolled in.
All fields marked with * must be completed.

This form is for students who are NOT able to take the test at The University of Mississippi campuses in Oxford, Desoto, Tupelo, Booneville. If you plan to take a test at any UM campus, please schedule your appointment through Online Learning Test Scheduler.
STUDENT & COURSE INFORMATION
Student Name*		Student ID Number*
Email Address*		- - Daytime Phone Number*
Mailing Address*	City*	State*	Zip*
Course Number and Title*		Name of Instructor*

TEST SITE & PROCTOR INFORMATION
Name of Test Site*		Country (if outside U.S.A.)
Proctor's Name*		Proctor's Official Title*
Proctor's Email Address*		- - Proctor's Phone Number*
Proctor's Mailing Address*	City*	State*	Zip*

EXAMINATION APPOINTMENT INFORMATION
I have contacted the person whose name appears above, and he/she has agreed to supervise an examination on the following date(s) and time(s).
Name of Test #1*	Test #1 Appointment Date*	Test #1 Appointment Time
Name of Test #2	Test #2 Appointment Date	Test #2 Appointment Time
Name of Test #3	Test #3 Appointment Date	Test #3 Appointment Time
Name of Test #4	Test #4 Appointment Date	Test #4 Appointment Time
Name of Test #5	Test #5 Appointment Date	Test #5 Appointment Time
Additional Comments
If a person has a disability that qualifies under the Americans with Disabilities Act and requires accommodations, he or she should contact the Office of Student Disabilities prior to requesting or scheduling an examination; 234 Martindale Center; P.O. Box 1848. University, MS 38677; phone 662.915.7128; TTY 662.915.7907; fax 662.915.5972; email sds@olemiss.edu. By submitting this form, I agree to Independent Study & Online Learning Proctored Assessment Policy as appeared below. Click here for a printable version of the policy.** * Ole Miss Online students must comply with the Proctored Testing Policy for web-based or online courses. * If an online or web-based course requires proctored assessments, then it is the responsibility of the individual taking the course (hereinafter “student”) to schedule proctored assessments. * All proctored assessments must be taken under the supervision of an approved test site official (hereinafter “proctor”). * All students must use a proctor who has been approved by the Department of Online Learning and Independent Study. * The Department of Online Learning and Independent Study reserves the right to reject any proctor and to require the student to come to a campus of the University of Mississippi to take the proctored assessment. * Students requesting special testing accommodations must provide copies of the appropriate documentation from the University of Mississippi’s Office of Student Disability Services to the Department of Online Learning and Independent Study no later than seven (7) working days prior to the student’s first proctored assessment each semester. * Students who are unable to sit for a proctored assessment at the main campus or one of the regional campuses of The University of Mississippi must submit an “Off-Campus Exam Request Form” in a timely manner as outlined below. * The Department of Online Learning and Independent Study should receive a student’s completed “Off-Campus Exam Request Form” as early as possible, but no later than seven (7) working days prior to the opening of the testing window for each proctored assessment. * If an “Off-Campus Exam Request Form” is received after the stated deadline, it is possible that the exam will be received by the proctor after the appropriate testing date thereby affecting the student’s grade. Additionally, the processing fee for late submissions of the “Off-Campus Exam Request Form” is $40 per exam if in the U.S. and $60 per exam if outside the U.S. These fees will be charged to the student’s Bursar account. * The Department of Online Learning and Independent Study cannot accommodate an “Off-Campus Exam Request Form” received less than forty-eight (48) hours before the scheduled exam date and time. The forty-eight (48) hours rule applies to workdays only. You cannot submit a form on a Friday and expect to test on the following Monday. * If an exam must be sent via express mail to meet a testing deadline as a result of a student’s delay in submitting the completed “Off-Campus Exam Request Form” or because of inaccuracies on the application, the express mail charges will be charged to the student’s Bursar account. * It is the responsibility of the student to pay the proctor fees required by some testing centers. Enter words shown above separated by space*