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leave this window open so the monitor can input the ending time of the exam.

Some affidavits request that you fill out and mail to Broker Educational Sales & Training, Inc.
By clicking the Submit button below the affidavit is being electronically sent to them.

You may want to print this page after filling out all the details as a record for yourself.



Virginia Student Certification

I do hereby swear and affirm, under oath, that I personally completed this exam without any outside assistance including course material, other source material or assistance from any person(s). I further swear and affirm that I was engaged in the course for at least an amount of time equal to the credit hours prior to taking the examination.

Course Name:

Course Number:

Signature (sign in ink only)
(You can sign this form by typing in your name)


Proctor Certification

I swear and affirm that I am over the age of eighteen years; that I am unrelated to the student identified in the Student Certification; that my execution of this certification was subsequent to the studentís execution of the Student Certification; and that I personally observed said student during the completion of this examination witnessing that he/she received no outside assistance from any source in completing the examination.

Course Name:

Course Number:


Name of Student

Address where exam was taken

Date exam was taken Beginning time Ending time

Type of monitor:



Print name of person administering test Job title of person administering test
Company/agency name Business phone number
Business mailing address
Signature of person administering test (sign in ink only)
(You can sign this form by typing in your name)

Before clicking Submit below
 Affidavit must be filled out completely for credit.
 Any missing information will delay credit to examinee.