IL Exam Request at site other than
the 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.
• Items noted with an *asterisk are required.

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

Exam Information

Today’s Date
*Exam Number or Name (e.g. Exam 1, Midterm)
*DATE Examination is Wanted
*TIME Examination is Wanted
*Course ID Number (e.g. ENG 100)
*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.

Select a Kentucky Testing Center Alice Lloyd College - Pippa Passes, KY Ashland Community College - Ashland, KY Bellarmine College - Louisville, KY Berea College - Berea, KY Brescia College - Owensboro, KY Campbellsville University - Campbellsville, KY Cumberland College - Williamsburg, KY Eastern Kentucky University - Richmond, KY Elizabethtown Community and Technical Assessment Center - Elizabethtown, KY Gateway Community College - Florence, KY Hazard Community College - Hazard, KY Henderson Community College - Henderson, KY Hopkinsville Community College - Hopkinsville, KY Kentucky Wesleyan College - Owensboro, KY Lees College of Hazard - Jackson, KY Lindsey Wilson College - Columbia, KY Madisonville Community College - Madisonville, KY Maysville Community College - Maysville, KY Military Only HQ USAARMC Bldg1174 - Fort Knox, KY Morehead State University - Morehead, KY Murray State University - Murray, KY Paducah Community College - Paducah, KY Pikeville College - Pikeville, KY Prestonburg Community College - Prestonburg, KY Somerset Community College - Somerset, KY Southeast Community College - Cumberland, KY St. Catherine College - St. Catherine, KY Thomas More College - Crestview Hills, KY University of Louisville - Louisville, KY Union College - Barbourville, KY WKU Regional Campus - Owensboro, KY WKU Regional Campus - Glasgow, KY Out of State

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