THE UNIVERSITY OF MISSISSIPPI
OLE MISS ONLINE

APPLICATION TO TAKE TEST OFF CAMPUS

Fill in complete information as requested below. Please use typewriter / word processor or write legibly. Students who plan to take the test at The University of Mississippi, Oxford Campus, are not required to complete this form.

STUDENT AND COURSE INFORMATION

Name (first)		(last)
Mailing Address	City	State	- Zip
- - Your Daytime Telephone Number
/ / Date Submitted
Course Subject, Number and Name
Instructor’s Name
Student Comments

Be sure to contact the Test Site before Submitting this form

TEST SITE AND SUPERVISOR INFORMATION

/ / Date of Test		Name of Test Site
Name of Test Supervisor		Official Title
Mailing Address	City	State	- Zip
- - Supervisor's Telephone Number

.

BY MAIL submit application to:

Department of Independent Study, The University of Mississippi,
P. O. Box 729
University, MS 38677-0729.

IN PERSON submit application to:

Department of Independent Study
Martindale Hall Room 371
Student Services Center, All American Drive
The University of Mississippi, Oxford Campus.

BY FAX submit application to: 662-915-1221

FOR OFFICE USE

_______________/______________/_________________/_________________
Received Enrollment date Date prepared/mailed Date student took test

_______________/____________________/_________________
Instructor Date sent to instructor Date received from instructor


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