EXAM MONITOR AFFIDAVIT

Exam Monitoring Affidavit to be completed in states where required - check the Monitoring Guide for guidance.

I certify that I administered the examination for the student and course stated below and that the exam was completed without assistance or outside help of any kind.

Student's Full Name: *

Course Title: *

State Requesting CE: *

Primary License #: *

NPN: *

MONITOR CONTACT INFORMATION

Monitor's Name: *

Insurance License # (Licensed monitor required for AZ, IN credit; otherwise mark "N/A"): *

Title: *

Business Name: *

Business Address (including city, state, zip code): *

Day Phone: *

Email address: *

Exam taken at monitor's location? *

Yes

No

Exam Location (if not the monitor's address), or "N/A": *

Type of licensee identification present if individual not known to monitor (i.e. photo ID, driver's license, etc), or "N/A": *

Monitor Signature: *

clear

Exam Date: * +

Estimated Exam Completion Time (hh:mm): *

We reserve the right to verify the validity of this information.

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