Please fill in all spaces as provided:

Student Name:

Student Contact Information

Email:

Phone:

Instructor Name:

School/institution/University Name Name:

Exam Date Request *

* Please list several possible dates.  The Library cannot guarantee that we will administer your exam on the date(s) that you’ve requested, but we will try to accommodate your request to the best of our ability.

Note:  If you experience difficulties with this form, please call 607-272-4556 or email proctor@tcpl.org.