Dakota State University

Proctor Agreement form for the MSIS Exam

Thank you for agreeing to proctor the IS exam for a Dakota State University student. Please review the Examination Proctor Guidelines. If you meet the qualifications and are willing to assume the responsibilities, please sign and submit this agreement form. Please contact the DSU Assessment Office at 605-256-5663 if you have any questions before, during, or after the examination.

Please return this completed Exam Proctor Agreement Form (fax preferred) to:

Dakota State University Assessment Office

Heston Hall #206

Madison SD 57042

FAX: 605-256-5093 PHONE: 605-256-5663 E-MAIL: carrie.ahern@dsu.edu

Student Name: _________________________________ Student ID ______________

TEST Information:

Testing Location: ____________________________________________________________

Testing Date and Time:___________________________________________________

PROCTOR Information:

Proctor Name:_____________________________________________

E-mail address: ____________________________________________

Position / Title:_____________________________________________

Business Address:___________________________________________________________

City State Zip _________________

Phone number during business hours:____________________________________________

area code number

PROCTOR SIGNATURE: ___________________________________________________

(Note: Examination instructions will be sent via e-mail )