054.00.50 Appendix G. Correspondence Course Certification of Completion and Proctor Affidavit f...
AR ADC 054.00.50 Appendix GArkansas Administrative CodeEffective: February 7, 2016
Effective: February 7, 2016
Ark. Admin. Code 054.00.50 Appendix G
054.00.50 Appendix G. Correspondence Course Certification of Completion and Proctor Affidavit for Use with Rule 50
All Correspondence Courses must have a proctored exam to be valid. Form must be typed or printed.
LICENSEE'S INFORMATION
Name of Licensee: _______________________________________________________
Licensee's's [FN1] License # ________________________________________
Resident Address: __________________________________________________ | |||
Street or P.O. Box | City or State | Zip | |
Business Phone # ___________________________________
Producer Signature _________________________ Date _________________________
PROCTOR INFORMATION:
Proctors Name: Proctors
Address: Proctors Phone
Number: _____________________________________________
Proctors Driver's License # ____________________ State of Issue __________
Start Time of Exam __________ End Time of Exam _______________
Date of Completion of Examination ________________________________________
Location of Examination __________________________________________________
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 | Date |
Once Licensee has tested and Proctor has completed form--Provider completes and sends to Department
CONTINUING EDUCATION PROVIDER INFORMATION (Completed by Provider only)
Course Name ________________________________________ Course # _______________
Provider Name ___________________________________ Provider's # __________
Signature of Provider Responsible Contact
Date:_______________
Instructions:
This completed form is to be returned to the Provider of the Course. No credit for the course will be given until the Provider has received this document. The Provider will provide a copy of this form to the Insurance Department by electronic media.
Credits
Amended Sept. 30, 2010; Feb. 7, 2016.
So in original.
Current with amendments received through February 15, 2024. Some sections may be more current, see credit for details.
Ark. Admin. Code 054.00.50 Appendix G, AR ADC 054.00.50 Appendix G
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