Please print this page, complete and submit to either
the Adult Services or Youth Services Librarian.

Patron Information

Name:    __________________________________

Address: __________________________________

                __________________________________

Phone:    __________________________________

Library Card #: _____________________________

Educational Institution Information

Institution Name: ___________________________

Teacher/Contact Person: ______________________

Subject/Class: _____________________________

Test Information

Please note that we do not proctor online tests.

Number of tests to be taken: ___________________

Date all tests should be completed by: ____________________

Please Circle the Testing Area Requested

Index table   (no privacy; schedule with Adult Services Librarian)

Study Carel   (some privacy; schedule with Adult Services Librarian)

Study Room   (maximum  privacy; schedule with Youth Services Librarian)

I have read and agree to all terms and conditions of the SFLD Proctoring Tests Procedures,

_______________________________                      __________________
Patron Signature                                                                          Date