PERSONAL RESPONSIBILITY

To be signed by student

AFFIDAVIT OF Self- study examinations must be proctored in a manner described below:

The proctoring process must ensure that the examination will be completed by the student on a closed-book basis and without assistance. The examination may be proctored by a corporate training department, supervisor-appointed co-worker or an approved test administration service; in any case, the proctor will be required to submit an affidavit to the sponsor stating that the specified conditions of administration were observed. Sponsors are required to submit examination performance data with renewal applications. Data should include the number of examinations administered, number passed, number failed, number of retakes, percent passed, percent failed, etc.

PERSONAL RESPONSIBILITY

To be signed by student

I declare that I personally completed this exam without any outside assistance including course material, other source material or assistance from any person(s).

________________________________________________________

Signature (sign in ink only)Date

AFFIDAVIT OF EXAM COMPLETION

To be completed and signed by exam monitor

I declare that I personally observed the above-named individual during the completion of this examination and also observed that the producer received no outside assistance in completing the examination.

_____________________________________________________________

Name of StudentName of Course Exam

______________________________________________________________________________

Address where exam was taken

_______________________________________________________

Date exam was takenBeginning timeEnding Time

Type of monitor __Corporate Training Dept.__ Supervisor___ Test administration service CEPP Instructor__ 

CEPP Representative__Special appointed __Co-worker __

____________________________________________________________

Print name of person administering testJob title of person administering test

____________________________________________________________

Company/agency nameBusiness phone number

______________________________________________________________________________

Business mailing address

___________________________________________________________

Signature of person administering testDate

(Sign in ink only)
 

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Fax: 703 852 4444



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