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leave this window open so the monitor can input the ending time of the exam.

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You may want to print this page after filling out all the details as a record for yourself.

 

 

Ohio

ATTESTATION OF PERSONAL RESPONSIBILITY
To be Signed by Student





I affirm that I personally completed the entire course study material. I also affirm that I completed the competency exam without assistance from any course material, other source material, or received outside assistance of any kind from any person, directly or indirectly, while taking the exam.

I have not used any fraudulent or deceptive means to complete this course.


Course Name: 



Name of Student (please print legibly)

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


** The examination may be taken without a proctor provided the student presents to the provider this sworn acknowledgement.


Please return the original signed attestation to:

Broker Educational Sales & Training, Inc.
7137 Congress Street
New Port Richey, FL 34653

ATTN: Self Study Department

**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.