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.