Student Information:
    Your First and Last Name:
    6 digit Student ID Number:
    Phone: (ie 555-123-4567)
    Fax:
    E-mail Address:
   
Proctor Information:
    First and Last Name:
    His/Her Profession Working Title:
    Mailing Address  Line 1:
    Mailing Address  Line 2:
    City:
    State or Province:
    Country:
    Zip or Postal Code:
    Home Phone # (ie 555-123-4567):
    Work Phone # (ie 555-123-4567):
    Fax:
    E-mail Address:


Note: Your proctor must be an engineer, architect or other professional; a lawyer or other court official; a minister or other church official in a church or religious community; a professional educator, teacher, instructor, lecturer or professor in accredited public school system, college, technical institute or university member; a member of a military, municipal, provincial or federal police force.   Please be sure to fill in all fields
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