ARKANSAS INSURANCE DEPARTMENT
APPENDIX G
AFFIDAVIT OF PROCTOR
FOR USE WITH 2006 EMERGENCY RULE 50
COURSE PROVIDER NAME CEIS
PROVIDER NUMBER 1391
CONTACT PERSON EDWARD HULSE
PROVIDER ADDRESS 12360 US HWY 19
CITY/STATE/ZIP HUDSON, FL. 34667
PHONE (800) 783-9440 E-MAIL ceisce@aol.com
Name of Licensee Taking Examination _______________________________________
Arkansas Producer License Number(s) _______________________________________
Course Title/Name ______________________________________________________
Date of Examination _____________________________________________________
Location of Examination __________________________________________________
Start Time: _________ End Time: ________________________
(Appendix G must be attached to Appendix H)
* * * * * * * * * * *
Proctor Name (Type or Print) ______________________________________________
Proctor DOB ___________________ DOI License Number, if any _________________
I do hereby solemnly attest that I proctored the above correspondence examination provided to the above named licensee and that the examination was provided as instructed by the Correspondence Course Provider. I personally opened, sealed, and numbered Exam #_____ on site for the test taken and 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. I understand that this Affidavit is provided under oath or affirmation, and that false information shall be grounds for possible Insurance Code or Rule penalties. I will provide a complete and accurate copy of all my records to the approved Course Provider, who must maintain them for access by the State Insurance Department.
______________________________________ ______________________________
Signature of Proctor Date
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