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*Student First Name:

*Student Last Name:

*Student Email:

*Student Phone:

*Name of the course:

*Instructor First Name:

*Instructor Last Name:

*Date that the class is taking the exam:

*Time that the class is taking the exam:
--- Select One ---8:00am8:30am9:00am9:30am10:00am10:30am11:00am11:30am12:00pm12:30pm1:00pm1:30pm2:00pm2:30pm3:00pm3:30pm4:00pm4:30pm5:00pm to --- Select One ---8:00am8:30am9:00am9:30am10:00am10:30am11:00am11:30am12:00pm12:30pm1:00pm1:30pm2:00pm2:30pm3:00pm3:30pm4:00pm4:30pm5:00pm
*Requested Exam Date in Test Center:
(Must allow 48 business hours in advance)
*Requested Exam Time in Test Center:
--- Select One ---8:00am8:30am9:00am9:30am10:00am10:30am11:00am11:30am12:00pm12:30pm1:00pm1:30pm2:00pm2:30pm3:00pm3:30pm4:00pm4:30pm5:00pm to --- Select One ---8:00am8:30am9:00am9:30am10:00am10:30am11:00am11:30am12:00pm12:30pm1:00pm1:30pm2:00pm2:30pm3:00pm3:30pm4:00pm4:30pm5:00pm
*What is the format of the exam?
Traditional paper/pencil
Online
Other format

Will you be using a computer or assistive technology for this exam?
I am permitted to use my own laptop for this exam
I need a testing center computer
My exam is administered using Honorlock
I need a keyboard/to type or a spellchecker as an accommodation
I need assistive technology

*Please list accommodations you need or any other information you would like to tell us about the exam, other than extended time. Please note: exams that require a reader and/or scribe need to be requested one week in advance to allow for staff scheduling. :

*Please type the word :