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Affidavit Form Guide

Preparing People To Pass

PRELICENSING SELF-STUDY COURSE AFFIDAVIT

AFFIDAVIT OF PERSONAL RESPONSIBILITY

(to be completed by student)

I declare that I will personally complete this exam with no assistance from any person(s), course material, or any additional source of information. This exam will be proctored by an approved proctor who is an impartial, disinterested third party or currently licensed agent with no family or financial relationship to the student. Membership in a professional association/organization does not constitute a financial relationship.

First Name:

Last Name:

Date:

SSN (xxx-xx-xxxx):

Telephone Number:

State:

Affidavit of Exam Completion

To be Completed and Signed by Exam Monitor

I affirm, under penalty of perjury, that I will observe the completion of the exam of the self-study course listed above. I also affirm, under penalty of perjury, that the exam will be completed without assistance from any source.

IMPORTANT: Exam monitor CAN NOT be yourself, a family member, direct supervisor, or anyone who can benefit financially.

Affidavit Form Guide

Preparing People To Pass

PRELICENSING SELF-STUDY COURSE AFFIDAVIT

AFFIDAVIT OF PERSONAL RESPONSIBILITY

(to be completed by student)

First Name:

Last Name:

Date:

SSN (xxx-xx-xxxx):

Telephone Number:

State:

Affidavit of Exam Completion

To be Completed and Signed by Exam Monitor

Exam Monitor

First Name:

Last Name:

Address exam was taken:

Zip:

State:

Date exam was taken:

Relationship to Student:

I have read and understand the terms and conditions