Student Information

(* Denotes a required field)

Are you a current LCC online student who is requesting to test off-campus?
Yes No

*Student Name

*Student # SS#'s are not accepted.

*Birth Date January Febuary March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

*Student Telephone

*Student Address

*Student City

*Student State International Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Jersey New York New Hampshire New Mexico North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Wisconsin West Virginia Wyoming

Country, State or Province: .

*Student Zip/Postal code

*LCC Student Email Address
Click for help accessing your LCC email account

*Verify Email Address

*Semester Attending: Summer Spring Fall

Please list all on-line courses and instructors that you will be enrolled in this semester.

*Courses

*Instructors

Proctor Information

If requesting to test at the LCC Livingston County Center please do not use this form and instead fill our our Livingston Center Proctor Request Form

*Proctor Name

*Proctor Location

*Proctor Address

*Proctor City

*Proctor State International Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Jersey New York New Hampshire New Mexico North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Wisconsin West Virginia Wyoming

Country, State or Province: .

*Proctor Zip/Postal code

*Proctor Email

*Verify Proctor Email

*Proctor Telephone

Proctor Fax

*Have you used this proctor location in previous semesters? If yes, what semester?

*Do you know the proctor on a personal or professional basis?

Yes No

If yes, Please explain.

Do you require special testing accommodations, if so please explain. (Please note that documentation may need to be provided for your request)

Other Comments

ATTENTION:

The Online Testing Support Office will not process your request, unless the form is complete.

The Online Testing Support Office requires seven to ten businesses days to process a request. You will receive an email notification once your request is processed.

For additional information, please visit our website at www.lcc.edu/assessment/

If you have any questions or concerns, please contact our office at:

1-800-644-4522 x5503 or by email at lcc_online_testing@lcc.edu

form r2.0