New York Monitor Affidavit
This form is to be filled out by the Exam Monitor Only
All online courses must have a New York State Approved Monitor witness each exam for credits to be earned.
LICENSEE’S INFORMATION
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Question 1 of 7
1. Question
Enter the Examinee’s Name Here
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Question 2 of 7
2. Question
Enter the Examinee’s Address Here
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Question 3 of 7
3. Question
Confirm the Examinee’s Identity by Photo ID. Please enter the ID Number Here
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Question 4 of 7
4. Question
Enter the Examinee’s Insurance Licence Number Here
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Question 5 of 7
5. Question
The Examinee shown as the registered student for this course is in fact the person taking the exam and without any assistance or without any reference material.
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Question 6 of 7
6. Question
ATTESTATION
I do hereby solemnly attest that by electronically entering my name here, I am currently a New York State Approved Monitor.
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Question 7 of 7
7. Question
Enter Your New York State Monitor Approval Number Here
