National Board of Surgical Technology and Surgical Assisting (NBSTSA) Examination Proctor Request Form

If you are interested in becoming an NBSTSA Examination Proctor, please complete and submit this form. PSI's Test Event Scheduling Team will then process and advise of next steps within 48 business hours.

Name of Institution *

Date of next test administration *

Address Details

Street *

City *

State *

Zipcode *

Proctor Contact Information

Name of Proctor *

Daytime Telephone *

Cell phone *

Email Address *

Surgical Technology Program Director Information

Program Director Name *

Program Director Daytime Telephone *

Program Director Email Address *

Comments *