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Assessment Test Request


Timertimer
* = required field
Date: 04/17/2014

Assessment Test Request Form

STANDARDS OVERVIEW for ACCUPLACER TESTING ADMINISTERED on BEHALF of M State. The rules we work under require the proctor be employed in a professional position (school, government agency, qualified business, etc). Further, we are required to validate that the email address of the proctor is a school, government agency, or qualified business address and not a personal, home, or free mail account. The proctor cannot be a family member or friend, be employed within a business owned by a family member or friend, or be supervised by a family member or friend.  Additionally, the proctor must ensure testing conditions, including identification of the test taker, professional setting (school, agency or business), adequate computer and Internet access, quiet and uninterrupted setting, and prevention of test taker having any access to materials outside those provided by the test administrator. The proctor is also responsible to ensure no other person has in-person, electronic, any other form of access to the test taker during the testing period. At the discretion of M State, the proctor candidate may be asked to complete the assurance form that is validated by a Public Notary.

Student Information

Student Name Address Student ID
*      
City State Zip
* * *
Email Intended Major
* *
Proctor Information
Name Job Title Email
* * *
Relationship to Student Business Name Business Address
* *   
City State Zip
* * *
Phone (###)###-####
*
Please submit this form to M State five (5) days before you plan to take the Accuplacer Assessment test.

The college is asking you to provide information which included private information under State and Federal law.  The information is optional; however, if you refuse to provide some or all of the optional information, the college may not be able to process your request.

www.minnesota.edu

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