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

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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:

Beginning Time:

Ending Time:

 
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.