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leave this window open so the monitor can input the ending time of the exam.

Some affidavits request that you fill out and mail to Broker Educational Sales & Training, Inc.
By clicking the Submit button below the affidavit is being electronically sent to them.

You may want to print this page after filling out all the details as a record for yourself.

 

 

ARIZONA
AFFIDAVIT OF PERSONAL RESPONSIBILITY
To be Signed by Student

I declare that I personally completed this exam without assistance from any person(s).

Signature (sign in ink only)
(You can sign this form by typing in your name)		 Date

AFFIDAVIT OF EXAM COMPLETION

To be Completed and Signed by Exam Monitor
Printed Name of Student:

     Name of Course:
Address Where Exam was Taken:

 City:

 State:

 Zip Code:
Date Exam was Taken:

  
Type of Monitor:    
(check one)
Provider Director Provider Number or AZ Insurance License Number of Monitor
An Arizona-licensed insurance producer appointed by the provider director
A person appointed by the provider directory who is in the business of administrating education or examinations


 
Printed Name of Monitor

     Job Title of Monitor:
Monitor's Company/Agency Name:

     Business Phone Number:
Business Mailing Address:

 City:

 State:

 Zip Code:

I declare that I personally observed the above named individual during the completion of this examination and also observed that the licensee received no assistance from another person in completing the examination.
 

Signature of Examination Monitor (sign in ink only)
(You can sign this form by typing in your name)		 Date

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

If you are printing this affidavit to send to Broker Educational Sales & Training, Inc. then send to:
Broker Educational Sales & Training, Inc.
7137 Congress Street
New Port Richey, FL 34653
or fax to: 727-372-7585
or email to: processing@brokered.net

By pressing the Submit button below you are electronically sending this form to us.