ARKANSAS MONITORING AFFIDAVIT

LICENSEE INFORMATION

Name of Licensee: *

License #: *

Resident Address (street, city, state and zip code): *

Business Phone #: *

Producer Signature: *

clear

Date of Signature: * +

PROCTOR INFORMATION

Proctor's Name: *

Proctor's Address (street, city, state and zip code): *

Proctor's Phone Number: *

Proctor's Driver's License Number: *

State of Issue: *

Start Time of Exam: *

End Time of Exam: *

Date of Exam Completion: * +

Location of Examination (street, city, state and zip code): *

PROCTOR ATTESTATION:

I do hereby solemnly attest that I proctored the above examination provided to the above named 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.

I attest to the above statement. *

Yes, I attest

Signature of Proctor: *

clear

Date of Signature: * +

Your form will be automatically submitted to the CE Department of The National Underwriter Company for processing. If you have any questions, please contact nucocertificates@alm.com.

CONTINUING EDUCATION PROVIDER INFORMATION (Completed by Provider only)

Course Name:

Course Number:

Provider Name:

Provider #: