Exam Request Form

Please fill in the following information. Click on the "Submit" button to submit your request.

All preceding required assignments must have been submitted to the instructor before this request may be sent. DO NOT enclose the Examination Request in an assignment.

If you have questions please call us at 303-492-5148.

* indicates a required field

First Name *

Last Name *

Student ID (last 4 digits) *

Address *

Address 2

City *

State *

Zip *

Country

Daytime Phone Number *

Email Address *

Instructor's Name

Course Abbreviation&Number *

Course Title

Course Type

Online: by mail:

Examination Number*
(Midterm, Final, Exam 1, etc)

Is this take home exam?

Yes: No:

NOTE: If you are taking the exam at the Continuing Education office, please check the Yes button, then the proctor infomation will be pre-filled for you. If not, please complete the following section with your proctor's information.The Independent Learning Program cannot be responsible for the proctor's receipt of examination(s) if insufficient time is allowed for mailing.

Are you taking the exam at the Continuing Education office?	Yes: No:
Name of Proctor *
Offical Position *
Daytime Phone Number *
Name of School/Business *
Business Street Address *
Address 2
City *		State *	Zip *
Country