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Take a quick look at this affidavit. If the affidavit requires a beginning and ending time field
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.

 

 

MASSACHUSETTS
AFFIDAVIT OF PERSONAL RESPONSIBILITY
To be signed by Student

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

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

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 student received no outside assistance in completing the examination.

Student Name:
                          (printed name)

Course Name:


Examination Location/Date & Time:


 Date:       


MONITOR: DISINTERESTED THIRD PARTY

Print name of person administering test
Job title of person administering test
Company / Agency name
Business/Daytime Address
Business/Daytime Phone
Signature of person administering test
(You can sign this form by typing in your name)

 
Completion date
 
 




**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.

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.