CCC Military Education Programs
FAX TO: (714) 241-6324
E-mail to: military@coastline.edu
 

Mail to:

CCC Military Education Programs
 11460 Warner Ave.
 Fountain Valley, CA 92708-2597

 

STUDENT / PROCTOR FORM (This form is not the "Letter of Agreement" and is wholly separate.)

Section Number

Course Name

Course Start Date

________________
________________

________________________________________________
________________________________________________

___________
___________

Branch of Service: (circle one)
| Army | Army National Guard | Coast Guard | Marines | Navy | Other |

STUDENT AGREEMENT (Please print legibly)

As a student, I agree to the following:

  • to be responsible to locate a proctor (exam supervisor) and to set up an appointment for the midterm and final exams, according to published dates.
  • to be responsible for reimbursing the proctor for mailing expenses.

Student Name________________________________ Social Security # _____ - _____ - _______ 
 E-mail_____________________________________________________________
 Address_____________________________________ Phone Number (        ) ________ - ______ 
 City_________________________________________ State___________Zip Code____________

 

PROCTOR AGREEMENT (Please print legibly) (Coastline College reserves the right to disapprove any chosen proctor.)

As a proctor, I agree to the following (Check those that apply): 

I am an education official or librarian or a teacher at a community college, university, elementary or secondary school.

I am a testing administrator or an educational services officer for the military.

I am an E-6 or above (if student is deployed).

I also agree to the following:

  • I am not a current student at Coastline. I am not a relative of the student, nor do I live at the same address as the student.
  • I will personally, on a voluntary basis, administer and supervise the indicated exams.
  • I will personally mail the completed exam(s) back to Coastline Community College immediately after the student has completed the exam(s).


Proctor Name ____________________________________Title / Rate  ______________________

E-mail_____________________________________________________________

Institution _________________________________________________________________ 

Mailing Address for Exams: (Please use an address that will ensure your receiving the Testing Materials in a timely manner. 
FPO addresses have not been successful for delivery)

 

Address __________________________________________________________________

City __________________________________________State _______Zip Code ________

Phone Number:    Work (          ) ____ - ______      or      Home   (          ) ____- _______

Proctor Signature________________________________________Date___________