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MISSOURI DEPARTMENT OF INSURANCE
FINANCIAL INSTITUTIONS AND PROFESSIONAL REGISTRATION
LICENSING SECTION
AFFIDAVIT OF EXAM PROCTOR
 
P.O. BOX 690 OR
P.O BOX 4001 FOR CORRESPONDENCE WITH FEES
JEFFERSON CITY, MO 65102
TELEPHONE: (573) 751-3518
 
DO NOT SEND THIS FORM TO THE MISSOURI DEPARTMENT OF INSURANCE, FINANCIAL INSTITUTIONS AND PROFESSIONAL REGISTRATION. YOU MUST SEND THIS FORM TO THE CONTINUING EDUCATION PROVIDER.

Self-study courses must have a proctored, closed book examination. Course and personal notes may not be used. An exam proctor is defined by 20 CSR 700-3.200 as a determined third party of at least eighteen (18) years of age, who has no corporate, employment or personal relationship, or other interest, in the studentís performance on the examination.

If the final examination is in written form, it will be provided to you in a separate, sealed provider envelope to be opened by you when the student is ready to start the examination. Upon completion of the examination, you will place the examination in the envelope provided and mail it to the provider.

In the case of the computer or internet exam, you will need to witness the student accessing the examination. You will then follow any on-line instructions for completing and submitting the proctor statements.

 
1) PRODUCER NAME

ID NUMBER

 

2) DO YOU KNOW THE STUDENT

YES    NO              HOW
if no, please confirm the studentís identification by requesting a photo ID
 

 

3) DATE EXAM TAKEN

LOCATION EXAM TAKEN

 

4) START TIME OF EXAM

STOP TIME OF EXAM

 

I hereby certify that I verified the identification of the student and administered the final examination in accordance with the Course Providerís instructions and I certify that it was complete without assistance or outside help of any kind. No copy of exam was made and it will be returned to the course provider immediately via mail or electronic submission (if computer or internet course/exam).

 

SIGNATURE OF PERSON ADMINISTERING EXAM  (You can sign this form by typing in your name)

 

PROCTOR'S PRINTED NAME

 

BUSINESS MAILING ADDRESS

 

BUSINESS TELEPHONE NUMBER

 

MO 375-0102 (8-06)

Before clicking Submit below

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