Thomas Edison State University


Keep a copy of this form for your records

Student Information

Student Name *

University ID Number *
Address *
City *
State: *
Zip *
Telephone Day Fax
E-mail Address *
Semester *
Course Title *
Course Code *
Choose one of the following methods*

Method 1: Select the state/country and base at which your exam will be administered. Within 7 business days of submitting this form, you will receive a Proctor Verification email listing the office and the mailing address to which your exam will be mailed. You must contact that office/proctor/center directly to arrange for a specific test date and time.

*Please contact your proposed Education Office prior to submitting this form to ensure that office will administer your exam(s).


Choose State/Country:

  Select Test Site:

Method 2: Method 2 is to be utilized only for locations not listed in Method 1. If you have any questions about completing this form, please contact .


Proctor Name:


Proctor's Rank/ Title:


Proctor's Work Email:

* Required Fields


  • This form must be submitted to the Office of Test Administration by the end of the first week of the semester.
  • Submit this form for each course in which you are enrolled at the beginning of each new semester.
  • Print this form for your records before submitting electronically.
  • If you do not receive email verification within 7 business days, please contact the Office of Test Administration at