Course: CS140 - Introduction to Computers   
Term: ______________

Student___________________________________ Student Number______________

Student e-mail address______________________Student fax number_________
          
Instructor: Dr. B. J. Shrestha 

Instructor's e-mail address: shrestha@umr.edu
           
Instructor's phone: (573) 341-6068    Instructor's fax number: 
(573) 341-4532 

Instructor's mailing  address: 604 Fox Creek, Rolla, MO 65401

_______________________________________________________________________

Name of Proctor______________________ Proctor phone number_____________

Proctor fax________________________ Proctor e-mail 
address_____________           

Proctor mailing address________________________________________________

_______________________________________________________________________

Relationship of proctor to student_____________________________________ 

Years known________
 
As proctor, I agree to identify the student via photo identification and
to ensure that the work done by the student will be completed according
to the instructions prepared by the instructor.

I agree to proctor:__________________________  Date____________________ 
                        (proctor signature)

Park College appreciates your support of this student.

Proctor: Please return this form to the instructor at the address above.