23 CAR pt. 18, Appendix G. Correspondence Course Certification of Completion and Proctor Affidavit

ARKANSAS INSURANCE DEPARTMENT APPENDIX G CORRESPONDENCE COURSE CERTIFICATION OF COMPLETION AND PROCTOR AFFIDAVIT FOR USE WITH RULE 50 All Correspondence Courses must have a proctored exam to be valid. Form must be typed or printed. ATTESTATION: I do hereby solemnly attest that I proctored the above correspondence examination provided to the above name licensee and that the examination was provided as instructed by the Course Provider. I assure the Commissioner that no attendee was permitted to use study materials or have assistance during the exam. Further, I am not part of, or aware of any efforts to circumvent the requirements of the proctored examination, and I have no special interest to ensure the licensee passes the examination. I understand that this affidavit is provided under oath or affirmation, and that false information shall be grounds for possible Arkansas Insurance Code or Rule penalties. Signature of Proctor Date Once Licensee has tested and Proctor has completed form—Provider completes and sends to Department CONTINUING EDUCATION PROVIDER INFORMATION (Completed by Provider only) Course Name Course # Provider Name _____________________________________ Provider's # Signature of Provider Responsible Contact Date: 19 Street or P.O. Box City or State Zip Start Time of Exam _____________ End Time of Exam Date of Completion of Examination _________________ Location of Examination LICENSEE'S INFORMATION Name of Licensee: Licensee's's License # Resident Address: Business Phone # _ Producer Signature Date PROCTOR INFORMATION: Proctors Name: Proctors Address: Proctors Phone Number: Proctors Driver's License # State of Issue Instructions: This completed form is to be returned to the Provider of the Course. No credit for the course will be given until the Provider has received this document. The Provider will provide a con/ of this form to the Insurance Department by electronic media.