23 CAR pt. 18, Appendix G
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.
LICENSEE'S INFORMATION
Name of Licensee: ______
Licensee's License # ______
Resident Address: ______
Street or P.O. Box
City or State
Zip
Business Phone # ______
Producer Signature ______
Date ______
PROCTOR INFORMATION:
Proctors Name: Proctors ______
Address: Proctors Phone ______
Number: ______
Proctors Driver's License # ______
State of Issue ______
Start Time of Exam ______
End Time of Exam ______
Date of Completion of Examination ______
Location of Examination ______
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: ______
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.