CE PROFESSOR IOWA AFFIDAVIT OF PERSONAL RESPONSIBILITY

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IOWA INSURANCE DIVISION
Continuing Education Program
Affidavit of Personal Responsibility
TO BE SIGNED BY THE STUDENT
I declare that I personally completed this exam without any outside assistance, including course material, other source material, or assistance from any person(s).
Signature *
N/A

E-Signature Field
Clear
Date Signed *
N/A

MM/dd/yyyy

Affidavit of Exam Completion
TO BE COMPLETED AND SIGNED BY EXAM MONITOR

I declare that I personally observed the above-named individual during the completion of this examination and also observed that the producer received no outside assistance in completing the examination.
Student Name
N/A

Required First Name Required Last Name
Course Name *
N/A
Student Email *
N/A
Iowa Provider #47896
Address Where the Exam Was Administered *
N/A
Exam Date *
N/A

MM/dd/yyyy
Type of Proctor/Monitor *
N/A

Provider Representative
Disinterested Third Party
Proctor/Monitor Name
N/A

Required First Name Required Last Name
Proctor/Monitor Title
N/A
Proctor/Monitor Business Name
N/A
Proctor/Monitor Phone Number *
N/A
Proctor/Monitor Email *
N/A
Proctor/Monitor Address
N/A

Required
Street Address
Address Line 2 Required City Required State/Region/Province Required
Postal / Zip Code

-Select-
Country
Proctor/Monitor Signature *
N/A

E-Signature Field
Clear
Proctor/Monitor Date Signed *
N/A

MM/dd/yyyy
Before clicking Submit below

The affidavit must be filled out completely for credit.
Any missing information will delay credit to the examinee.

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