IL Exam Request at site other than
the WKU DL Testing Center

• Before filling out and submitting this form, please make sure you submitted all assignments prior to the exam. If you have any questions concerning your exam contact the Office of Independent Learning, (270) 745-4158 or il@wku.edu.
• 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

Location of Your Testing Center

In Kentucky
Not in Kentucky

For Test Locations in Kentucky

• 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 - Pippa Passes, KYAshland Community and Technical College, Ashland - Ashland, KYAshland Community and Technical College, Grayson - Grayson, KYBig Sandy Community and Technical College, Prestonsburg Campus - Prestonsburg, KYBluegrass Community and Technical College - Lexington, KYCampbellsville University - Campbellsville, KYEastern Kentucky University - Richmond, KYElizabethtown Community and Technical Assessment Center - Elizabethtown, KYFort Knox, WKU Regional Campus - Fort Knox, KYGateway Community and Technical College Center for Advanced Manufacturing - Florence, KYGlasgow Regional Campus, WKU - Glasgow, KYGreen County Adult Education - Greensburg, KYHazard Community and Technical College, Hazard - Hazard, KYHenderson Community College - Henderson, KYHopkinsville Community College - Hopkinsville, KYJefferson Community and Technical College - Louisville, KYKentucky State University - Frankfort, KYKnott County Branch - Knott County, KYLees College of Hazard - Hazard, KYLeslie County Center - Hyden, KYLindsey Wilson College - Columbia, KYMadisonville Community College, Madisonville - Madisonville, KYMadisonville Community College, Muhlenburg Co. - Central City, KYMaysville Community and Technical College, Licking Valley Campus - Cynthiana, KYMaysville Community and Technical College, Maysville - Maysville, KYMaysville Community and Technical College, Rowan Campus - Morehead, KYMorehead State University - Morehead, KYMurray State University - Murray, KYOwensboro Regional Campus - WKU - Owensboro, KYSomerset Community College - Somerset, KYSomerset Community College - Laurel Campus 1 - London, KYSomerset Community College - Laurel Campus 2 - London, KYUniversity of Louisville - Louisville,, KYUniversity of Pikeville - Pikeville, KYWest Kentucky Community and Technical College - Paducah, KY

For Test Locations Outside of Kentucky

If you wish to take your test outside of Kentucky, 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

Confirmation

I have contacted the person listed above and have set up an appointment for the time and date shown on this form. (NOTE: the form cannot be submitted unless this box is checked.)

I have completed all applicable assignments/lessons that are necessary to take this exam. (NOTE: the form cannot be submitted unless this box is checked.)