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Affidavit of Exam Completion

Please fill out the Affidavit below. This a WI OCI requirement, and credits cannot be processed without it. When finished, click the button to submit the form electronically. You may print a copy for your records before submitting. Do not send, fax or email an extra copy to me.

ALL FIELDS ARE REQUIRED

LICENSEE'S INFORMATION
PROCTOR INFORMATION

"An approved proctor is an impartial, disinterested third party or currently licensed agent with no family or financial relationship to the student. The proctor shall verify the agent's identity and complete an affidavit supplied by the approved provider testifying that the agent received no outside assistance. Membership in a professional association/organization does not constitute a financial relationship."

(h:mm) (h:mm)
(zip)

I certify, under penalty of perjury, that I verified the identification of the above student and that I was present with said student during the entire exam. I also certify that the student named below answered the exam questions without assistance from any source. (proctors initials:)

I affirm, under penalty of perjury, that I personally completed the entire study material of the course. I also affirm, that I completed the exam without any assistance from any course material, other source material, or from any person. (test taker/student initials:)

Typed Electronic Signature of Proctor: (this is a legal signature)
Date: (m/d/yy)
Typed Electronic Signature of Test Taker/Student: (this is a legal signature)
Date: (m/d/yy)

DO NOT EMAIL, SEND, OR FAX THIS FORM. THIS ELECTRONIC FORM IS ALL I NEED TO SUBMIT YOUR CREDITS. THANK YOU!