Affidavit Of Exam Proctoring Form - South Carolina Department Of Insurance
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2SOUTH CAROLINA DEPARTMENT OF INSURANCE
SOUTH CAROLINA DEPARTMENT OF INSURANCE - AFFIDAVIT OF EXAM PROCTORING
Please note: This form should be returned to the sponsor/vendor. The sponsor/vendor must keep a
copy of this affidavit with a copy of the exam for three (3) years after the exam was completed.
Section I – To be completed by Proctor
I certify under the penalty of perjury that I have verified the identification (including a photo ID and producer license number) of the said
producer named below. The producer completed the examination independently and without the assistance of any course materials,
other source materials, advance review of the examination or from any persons. I certify that the exam answer sheet and all scratch
paper given to the examinee were returned and no copy of the examination(s) was/were made by the examinee. I also certify that I
mailed/delivered the answer sheet and all other required materials to the vendor within two business days of the exam date. I hereby
certify that I have not made or retained copies of any examination or work papers for further distribution.
Further, I certify that I am a Disinterested Third Party and not someone who is: (A) a minor; (B) a relative of the producer; (C) an
immediate supervisor/manager of the producer, or (D) a person with an economic or other interest in assuring the successful outcome
of the examination.
NOTE: Employment by the same company or working for the same employer does not mean a person has ‘an economic or other direct
interest in assuring the successful outcome of the examination.’ For example: a co-employee or co-worker of the producer taking the
competency examinations may administer the examination so long as the other requirements of this subparagraph are met and such
co-employee or co-worker does not work on a regular basis with the producer in marketing or sales capacity the examinee is not
related.
Proctor’s Printed Name: ______________________________________________________________________
Proctor’s Business Mailing Address: _____________________________________________________________
Day Time Phone Number: ____________________________________________________________________
Signature of Proctor: _________________________________________________________________________
Section II – To be completed by Examinee
I certify under the penalty of perjury that I took the examination(s) independently and without the assistance of any course materials,
other source material, advance review of the examination(s), or from any persons.
I did immediately (Within 24 Hours), upon
completion of the examination(s) return the exam, and answer sheet and all scratch paper to ________________________________
No copy of the examination(s) was/were made.
(NAME OF CE COURSE SPONSOR)
Proctor’s Printed Name: __________________________________________________________________________
Date Exam Taken: _________________________Course Title ___________________________________________
Examinee’s Printed Name: _________________________________________________________________
Examinee’s Signature: _____________________________________________________________________
Examinee’s License Number: _______________________________________________________________
Section III – To be completed by Examinee
If you participated in a classroom review session, please answer the following questions:
______ I did
I did not _____ participate in a classroom review session. If so, provide course number __________.
Name of the individual who conducted my review session: _________________________________________
Date/time/location of review session: __________________________________________________________
Length of review session: _________________________
Did you receive your course material at least seven (7) days in advance of the review session? ________ If no, when did you receive
the course material? _________________________
SCID Form 3616 (Revised 11/1/2010)
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