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IOWA INSURANCE DIVISION
Continuing Education Program
Affidavit of Personal Responsibility
TO BE SIGNED BY STUDENT

 

SEND TO

Name
Broker Educational Sales & Training, Inc.

Address
7137 Congress Street, New Port Richey, FL 34653

I declare that I personally completed this exam without any outside assistance including course material, other source material or assistance from any person(s).

 

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

 

Affidavit of Exam Completion
TO BE COMPLETED AND SIGNED BY EXAM MONITOR

I declare that I personally observed the above named individual during the completion of this examination and also observed that the producer received no outside assistance in completing the examination.
 
Name of Student 
Name of Course
 
Address where exam was taken
 
Date exam was taken
 
Beginning Time
Ending Time
Type of monitor: (check one)    
  Provider Representative
  Disinterested Third Party
Provider Number
Print name of person administering test
Job title of person administering test
Company / Agency Name
Business Phone Number
Business mailing address
 
Signature of Course Approved Monitor/CE Provider Representative
(You can sign this form by typing in your name)
Date

 


Copyright © 2010 Pearson Education, Inc. or its affiliates. All Rights Reserved                                                  Stock # 1216-13 12/10

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.