. Affidavit

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ARKANSAS INSURANCE DEPARTMENT
APPENDIX G
CORRESPONDENCE COURSE
CERTIFICATION OF COMPLETION AND PROCTOR AFFIDAVIT
FOR USE WITH RULE 50

 

All Correspondence Courses must have a proctored exam to be valid. Form must be typed or printed.


LICENSEE’S INFORMATION
Name of Licensee:
Licensee’s License #
Resident Address:
Street or P.O. Box City State Zip
Business Phone #
Producer Signature    Date
 

PROCTOR INFORMATION:
Proctors Name:
Proctors Address:
Proctors Phone Number:
Proctors Driver’s License #    State of Issue
Start Time of Exam End Time of Exam
Date of Completion of Examination 
Location of Examination
 

ATTESTATION:
I do hereby solemnly attest that I proctored the above correspondence examination provided to the above name licensee and that the examination was provided as instructed by the Course Provider. I assure the Commissioner that no attendee was permitted to use study materials or have assistance during the exam. Further, I am not part of, or aware of any efforts to circumvent the requirements of the proctored examination, and I have no special interest to ensure the licensee passes the examination. I understand that this affidavit is provided under oath or affirmation, and that false information shall be grounds for possible Arkansas Insurance Code or Rule penalties.

 

Signature of Proctor
(You can sign this form by typing in your name)
Date

 Once Licensee has tested and Proctor has completed form—Provider completes and sends to Department


CONTINUING EDUCATION PROVIDER INFORMATION (Completed by Provider only)
Course Name Course #
Provider Name Broker Educational Sales & Training, Inc. Provider’s # 11346
 

Signature of Provider Responsible Contact

  Date:

 

Before clicking Submit below
 
 Affidavit must be filled out completely for credit.
 Any missing information will delay credit to examinee.