CE PROFESSOR WEST VIRGINIA AFFIDAVIT OF PERSONAL RESPONSIBILITY

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AFFIDAVIT OF PERSONAL RESPONSIBILITY
To be Signed by Student

I declare that I personally completed this exam without any outside assistance including course material, other source material, or assistance from any one person(s).
COURSE TITLE *
N/A
STUDENT NAME
N/A

Required First Name Required Last Name
STUDENT EMAIL *
N/A
STATE INSURANCE LICENSE NUMBER *
N/A
STUDENT PHONE NUMBER *
N/A
ADDRESS OF EXAM *
N/A
STUDENT SIGNATURE *
N/A

E-Signature Field
Clear
DATE SIGNED BY STUDENT *
N/A

MM/dd/yyyy

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