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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.




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)

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

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

**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.

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.