FLS Remote Testing Request Form

This form is for institutions wishing to schedule an FLS remote testing date for at up to ten test candidates in a single day.

This form must be submitted at least three months prior to any requested dates. Once the form is received by SAGES and one of the requested dates is confirmed, an invoice will be generated and emailed to the contact person designated on the form. Invoices must be paid 30 days prior to the requested test date.

Once a test date is confirmed, the institution must submit images to SAGES of the FLS Trainer Box, monitor, and instruments that will be used on testing day. These images must be received within two weeks of receipt of the reservation confirmation email.

I understand that filling out this form does not guarantee a Remote Testing Date. In the event that none of the preferred dates listed above are available, I understand the SAGES office will contact me directly to let me know and I may have to fill out an additional request form. I understand that failure to fill out this form correctly or completely may result in no response from the SAGES office. I understand that FLS Remote Testing is reserved for up to eight eligible test candidates prepared to take the FLS exam on the scheduled date.

All test dates I have listed above are accurate and will be accommodated by our facility if confirmed.