SOUTHERN POLYTECHNIC STATE UNIVERSITY
Quality Assurance Program
Proctor Registration Form


A separate proctor form must be submitted each for each course the student is enrolled in.

Student Information

Student Name: ______________________________________________________________

Student Signature: ___________________________________________________________

Course: ___________________ Semester: ________________________


Proctor Information

The above student has asked me to serve as proctor for the final exam in the Master of Science in Quality Assurance college course in which he or she is enrolled, and I have agreed to accept that responsibility.

There is nothing in my relationship with the student that represents a conflict of interest or bias toward the student in carrying out the duties of proctor for this final exam.

Are you related to the above student through birth or marriage? ___ Yes or ___ No
Do you work for the same company as the above student? ___ Yes or ___ No
Is the above student your supervisor at work? ___ Yes or ___ No

Proctor's Signature: __________________________________Today's Date: __________

Proctor's Printed Name: ______________________________________________________

Street Address: ______________________________________________________________

City: _____________________________ State: ______________ Zip Code: ________________

Telephone: ____________________ Fax: ____________________ Email: ____________________

Employer: _______________________________________________________________________


Either FAX this form to (770) 528-4991 or mail to the following address:
SPSU, MSQA Department
1100 South Marietta Parkway
Marietta, GA 30060-2896