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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.



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)
(You can sign this form by typing in your name)

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


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
(You can sign this form by typing in your name)
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.