SOUTHERN POLYTECHNIC STATE UNIVERSITY
Quality Assurance Program
Proctor Registration Form
QA6640, Spring 2007
Professor Robert Atkins, P.E.


Student Information

Student Name: ______________________________________________________________

Student Signature: ___________________________________________________________

Are you currenting in the United States on a F-1 or J-1 visa? ___ Yes or ___ No


Proctor Information

The above student has asked me to serve as proctor for the final exam in the Master of Science in Quality Assurance college course in which he or she is enrolled, and I have agreed to accept that responsibility.

Proctor's Printed Name: ______________________________________________________

Employer: _________________________________________________________________

Street Address: ____________________________________________________________

City: _____________________________ State: __________ Zip Code: ________________

Telephone: __________________________ Fax: ______________________________

Email: _______________________________________________________________

Are you related to the above student through birth or marriage? ___Yes or ___No
Do you work for the same company as the above student? ___Yes or ___No
Is the above student your supervisor at work? ___Yes or ___No

There is nothing in my relationship with the above student that represents a conflict of interest or bias toward the student that would influence me in executing the duties of proctor for this exam.

Proctor's Signature: _______________________________ Today's Date: _______________


Please Fax this form to 678-915-4991 or mail the form to:
Professor Robert Atkins, P.E.
SPSU - MSQA/IET Department
1100 South Marietta Parkway
Marietta, GA 30060-2896