NATS Off-Site Exam Request Form

To ensure your request can be processed by the time of your examination, this form must be submitted at least 10 business days PRIOR to the exam date.

Name Name First Last
YorkU Email Address
Student Number
Must be 9 digits. Currently Entered: 0 digits.
Current Address:
Address on Location Current Address:
Address on Location
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Cell Phone Number
Confirm

Confirm I confirm that the current location and address I have provided above is where I am currently residing, and that it is more than 3 hours travel time from York University's Keele campus in Toronto, Ontario Canada.
Permanent Address: Permanent Address:
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Home Phone Number
Course ID# and Section:
(e.g. NATS 1775 A)
On-Campus Exam Date: On-Campus Exam Date: / MM / DD YYYY
On-Campus Exam Time: On-Campus Exam Time: : HH MM AM/PM
Course Instructor's Name: Course Instructor's Name: First Last
Time Zone Difference:
(how many hours ahead or behind Toronto Time)
Reason for not attending On-Campus Exam:
Special Needs (Applicable only to students registered with Counselling & Supervision Services):

If you are a student registered with Counselling & Supervision Services [http://cds.info.yorku.ca/], please forward the official documentation that confirms your registration and accomodations/special needs to our office.
Invigilator Name: Invigilator Name: First Last
Academic Position Title:
Academic Institution, University/College or other:
Institution Mailing Address: Institution Mailing Address:
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Institution Web Address/URL:
Institution Telephone Number:

Please include area code numbers
Institution Fax Number:

Please include area code numbers
Invigilator Email Address:

Official academic e-mail only, commercial e-mail accounts not acceptable, e.g. hotmail, g-mail
Off-Site Exam Scheduled Date: Off-Site Exam Scheduled Date: / MM / DD YYYY
Off-Site Exam Scheduled Start Time: Off-Site Exam Scheduled Start Time: : HH MM AM/PM
Academic Honesty:
"By signing your name you affirm that you are registered in the couse. You also acknowledge understanding that cheating on an exam, including impersonation and plagiarism, is a breach of Academic Honesty and is punishable under the regulations of the Senate of York University."

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Today's Date: Today's Date: / MM / DD YYYY
Student Initials to verify that all information supplied here is valid:

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.