Name of Proctor: ____________________________________________

Address: ___________________________________________________

City/State/Zip Code: _________________________________________

Phone Number: ______________________________________________

Job Description: ______________________________________________

Name of student that you will proctor: ___________________________

By signing this Proctor Application you are agreeing to administer and mail the proctored exam back to CHDCA.  You will verify that the student takes no more than 2 hours, uses no books or notes, and makes no copies of the exam.

The student is to contact you and arrange a time that is convenient for the both of you to take the exam.  The exam will be mailed directly to you with a postage paid return envelope for you to mail it back to us.

I agree to proctor the exam and assure that no copies of the exam are made or that any of the questions are copied.

Print Name:  __________________________________________

Signature:  ___________________________________________

Student's Instructions:

1. Print this application
2. Give to local librarian that is willing to proctor your exam
3. Your proctor is to fill out this application and you are to mail to:
   Certified Hood & Duct Cleaners Association
   Attn:  Proctor Application
   110 Beverly Dr.
   Madison, TN 37115
4. Please call 1-888-848-6636 with any questions