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.


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


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)

24 Hour Enrollment Operator Assistance: 1 800 232 6465
9 - 5 PM EST Office: 1 - 540 - 743 1733
Fax: 703 852 4444

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