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Nebraska
Affidavit of Course Completion


I affirm, under penalty of perjury, that I personally completed the entire text of the self-study course listed below. I also affirm, under penalty of perjury, that I completed the exam without assistance from any source. I understand that it is my responsibility to file or maintain my Certificate of Completion as required by any Department of Insurance or other regulatory agency with which I intend to register continuing education credit.
 

Name of course completed Course Number Date completed
Name (Typed or Printed)
Signature (sign in ink only)
(You can sign this form by typing in your name)
Date

AFFIDAVIT OF EXAM COMPLETION
To be Completed and Signed by Exam Monitor


I certify that I verified the identification of the student. In addition, I administered the final examination and certify that it was sealed until administration and completed without assistance or outside help of any kind.
 

Name of Student Name of Course  
Address where exam was taken
Date exam was taken Beginning Time Ending Time

MONITOR: DISINTERESTED THIRD PARTY

Print name of person administering test Job title of person administering test
Company / Agency name Business phone number

Business mailing address

Signature of person administrating test (sign in ink only)
(You can sign this form by typing in your name)
Date

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