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 student’s 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.
| I hereby certify that I verified the identification
of the student and administered the final examination in
accordance with the Course Provider’s 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). |
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