WKU Independent Learning Examination Request Form
(at site other than WKU DELO Testing Center)

Before filling out and submitting this form, please contact the Office of Independent Learning, (270) 745-4158, to make sure you are eligible to take your exam.
It is your responsibility to make arrangements with the center at which the exam will be supervised.
If you are taking online courses from WKU Distance Learning, KYVU, SREB, or need other proctoring services, do not use this form. It is only to be used for WKU Independent Learning course examination requests.

IMPORTANT: You must present a valid photo ID before being allowed to take your exam.

Exam Information

Today’s Date
Exam Number or Name
DATE Examination is Wanted
TIME Examination is Wanted
Course ID Number
Course Title
Course Instructor

Your Contact Information

Your name
Address Line 1
Address Line 2
City or County
State
Country
Zip Code
Your email address
Your phone number

Student Information

Are you graduating this semester?	Yes No
Are you receiving financial aid this semester?	Yes No

State Where You Live

Are you a resident of Kentucky?	Yes No

For Kentucky Residents

• Please indicate where you plan to take your exam.
• Note that these Kentucky centers may also be used by students in neighboring states who live within convenient driving distance.

For Non–Kentucky Residents

If you live out–of–state, you will need to make arrangements with a local community college or university. Approved supervisory personnel include directors of independent study programs, directors of testing or counseling services, directors of admissions, or academic deans. Non-administrative faculty members would not be approved to receive and administer these exams. Students on active duty in military service, or their dependents, may take examinations under the supervision of their base education officer or someone designated by that officer.

In accordance with the requirements listed above, please give your exam supervision information:

Exam Supervision Information

Exam Supervisor’s Name
Administrative Title
Institution Name	(Must be Post-secondary Institution or Military Education Office)
Institution Address Line 1
Institution Address Line 2
Institution City or County
Institution State
Institution Country
Institution Zip Code
Institution Phone
Institution Email address

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WKU Independent Learning, a Unit of the Division of Extended Learning and Outreach

WKU Independent Learning Examination Request Form (at site other than WKU DELO Testing Center)

Exam Supervision Information

WKU Independent Learning Examination Request Form
(at site other than WKU DELO Testing Center)