Proctor Information

Form Submitted By

First Name

Last Name

Student Information

Student First Name

Student Last Name

UNHS Student ID (optional)

Approve this proctor for ALL current courses OR Approve this proctor for ONLY the following courses. (List all courses to be approved for this proctor. Separate each course with a comma.)

Proctor Information

Proctor First Name

Proctor Last Name

Position/Job Title

Organization or School Name

Phone

Address

Address 2 (optional)

City

State

Zip / Postal Code

Country

Address Type Business Residential

Is the Proctor Related to the Student? Not related to student Related to the student

If related, how is the proctor related to the student?

University of Nebraska High School, Proctor Information