Name of Licensee (*Required)

Licensee’s License Number (*Required)

Resident Address (*Required)

Street or P.O. Box

City, State, Zip

Business Phone Number (*Required)

Producer Signature (*Required)

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Date (*Required)

PROCTOR INFORMATION:

Proctor’s Name (*Required)

Proctor’s Address (*Required)

Street or P.O. Box

City, State, Zip

Proctor’s Phone Number (*Required)

Proctors Driver’s License Number (*Required)

State of Issue

Start Time of Exam (*Required)

End Time of Exam (*Required)

Date of Completion of Examination (*Required)

Location of Examination (*Required)

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 (*Required)

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Date (*Required)