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T-III (20) -- CERTIFICATION FORM
for April 20, 2005
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Please fill out one form for each student you have participating in the USAMO.
Please print the name and USAMO Number of your student participating in the 2005 USAMO below:
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Name USAMO Number
This form must be completed and returned by fax (303/374-6339) to the AMC Office immediately following the administration of the USAMO. Both the USAMO School Exam Manager and the school Principal or Vice Principal must sign this form. The Principal or Vice Principal must sign at the time he or she observes the downloading of the exam. The Exam Manager must wait until all aspects of the exam process of the school have been completed.
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For the Principal or Vice Principal:
| I Certify that |
| a) |
I witnessed the downloading of the test at the start of the examination; |
| b) |
I further attest that I observed that the exam was given only to qualified students; |
| c) |
I accept that failure to follow these rules and procedures could result in DISQUALIFICATION from official standing of all scores from our school |
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| Signature: _______________________________________Time: _________________ |
| Title: ___________________________________________Date:_________________ |
| (must be comparable to Principal or Vice Principal) |
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For the USAMO School Exam Manager:
For the USAMO School Exam Manager:
I certify that I administered the USAMO on Tuesday, April 20, 2005 from 12:30 p.m.-5:00 p.m. EDT or equivalent in my time zone. The 4.5-hour time limit was strictly enforced. The student(s) was/were continually supervised. All other rules for administering the USAMO, as detailed in the Information for Proctor, were followed.
I understand and accept for our school that any exception to these procedures as outlined on the USAMO Exam Manager Letter and the Information for Proctors section, unless explicitly authorized in advance, may be cause for disqualification, possibly extending beyond the current year.
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| Signature of USAMO Exam Manager: ________________________________________ |
| Day and Date of Signature: ________________________________________________ |
| Your telephone # at School: (_______) _______________ |
| Email: _______________________________________________________________ |
| Name of School: _______________________________________________________ |
| CEEB: ___ ___ ___ ___ ___ ___ |
| School Address: ________________________________________________________ |
| _____________________________________________________Zip: ____________ |
| Day and Date USAMO was administered: _____________________________________ |
| Start Time: __________________End Time: ________________ |
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