Examination Request Form for
Independent Learning through Correspondence Only
Independent Learning students--You must contact the Office of Independent Learning through Correspondence to make sure that you are eligible to take your exam before filling out and submitting this form. 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 reachu, KYVU, SREB or need other proctoring service do not use this form.

You must present a valid photo ID before you will be allowed to take your exam.
Part 1 - General Information

NOTE: The fields marked with '*' must be filled out if applicable.

Date Examination is Wanted *  TIME 
                                                (MM-DD-YYYY)

Last Name *  First Name *  Middle Initial 

Email address *  Phone *

Address  City  State  ZIP Code 

Course ID  Course Title  Instructor

Exam Number or Name 

Are you graduating this semester?

Are you receiving financial aid this semester?

Part 2 - For Kentucky Residents

In accordance with the instructions, I plan to take my exam at
Note: The Kentucky centers may also be used by students in neighboring states who live within convenient driving distance.

Part 3 - For Out Of State Students

In accordance with the regulations governing the supervision of examinations given outside the state
of Kentucky, as explained on the General Information sheet in the packet, I plan to take my exam
under the supervision of :

Last Name     First Name     Middle Initial 

Administrative Title    

Name of Institution   
(Must be Post-secondary Institution or Military Education Office)

Address    City     State     ZIP Code    

Phone 

E-mail 


 
 
 
  For more information contact the il@wku.edu

Form 8/24/07