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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.

 

 

Virginia Student Certification



I do hereby swear and affirm, under oath, that I personally completed this exam without any outside assistance including course material, other source material or assistance from any person(s). I further swear and affirm that I was engaged in the course for at least an amount of time equal to the credit hours prior to taking the examination.

Course Name:

Course Number:

 
 4/25/2024
Signature
(You can sign this form by typing in your name)		 Date


 



Proctor Certification



I swear and affirm that I am over the age of eighteen years; that I am unrelated to the student identified in the Student Certification; that my execution of this certification was subsequent to the student’s execution of the Student Certification; and that I personally observed said student during the completion of this examination witnessing that he/she received no outside assistance from any source in completing the examination.

Course Name:

Course Number:

 

Name of Student

Address where exam was taken
Date exam was taken



Type of monitor:


Describe


 

Print name of person administering test Job title of person administering test
Company/agency name Business phone number
Business mailing address
Signature of person administering test
(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.

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.