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MASSACHUSETTS

CONTINUING EDUCATION ATTESTATION OF PERSONAL RESPONSIBILITY



I affirm that I personally completed the entire course study material. I have not used any fraudulent or deceptive means to complete this course. I further affirm that I completed the competency exam without assistance from any course or reference material, other source material, or outside assistance of any kind from any person or electronic device, directly or indirectly, while taking the exam.**

I understand that I may be subject to state administrative action, which may include the revocation of my Massachusetts insurance license, if the Division of Insurance determines that I have provided it with false information in this or any other statement to the Commissioner.


Course Name:


Examination Location/Date & Time:



Student Name:
                          (printed name)


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


On a temporary basis the continuing education examination may be taken without a proctor if the student presents this sworn acknowledgement to the educational provider.


Please return the original signed attestation to:

Broker Educational Sales & Training, Inc.
7137 Congress Street
New Port Richey, FL 34653

ATTN: Accreditation Department



**Credits will not be submitted until an attestation is received. You may fax the document to 727-372-7585 immediately after completing the examination and receiving notification that you have passed to expedite credit submission. However, the original must be mailed to the provider to be kept with your CE record.
 

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