PROCTORING AFFIDAVIT FOR

TEXAS ADJUSTER PRE-LICENSE FINAL

Student’s Name: Telephone #:

Mailing Address:

City: State: Zip:

State Driver’s License or ID#:

The below information must be completed by the Proctor. A Proctor must be someone who

falls under the below requirements defined by the Texas Administrative Code T.A.C. Title28 Part I Chapter 19 Rules 19.1002 (b)(12) and 19.1017 (e).

A disinterested third party shall monitor the final examination in a visual environment. During the examination, students may not use course materials, personal notes, or any other written or electronic material or media that is not part of the examination, nor engage in communication of any kind with any other person except to receive instructions from the examination monitor.

“Disinterested third party -- An individual who is: (A) not related to a student by blood,

adoption, or marriage as a parent, child, grandparent, sibling, niece, nephew, aunt, uncle, or

first cousin; or (B) not an employee or subordinate of the student.”

Pursuant to T.A.C Title 28 Part 1 Chapter 19 Rules 19.1018(a) - The student shall complete a 150 question examination in less than 180 minutes.

Proctor’s Name: Telephone #:

Proctor Address:

City: State: Zip:

State Driver’s License or ID #:

I hereby certify that the student listed on this affidavit will personally complete the final

exam for the Texas Adjuster Pre-License course. As the designated proctor, I will

personally witness the student complete this test without any outside materials or assistant.

I also adhere to T.A.C. Title 28 Part I Chapter 19 Rules 19.1002 (b)(12) and 19.1017 (e).

Proctors Signature: Date:

SWORN TO AND SUBSCRIBED before me

this _______ day of _____________ 20____.

____________________________ Notary Public

______________________________________________

My Commission Expires

Please email this form to affidavits@360training.com - (if emailed, it must be completed in blue ink)

or mail it to 360training.com, Attn: Accreditation Department, 13801 Burnet Road, Suite 100, Austin, TX 78727

Student Signature: Date:

(NOTARY SEAL)

TEXAS DEPARTMENT OF INSURANCE

AFFIDAVIT OF PERSONAL RESPONSIBILITY

I affirm, under penalties of perjury, that I personally completed 10 hours

of the Self Study portion of the Texas Adjuster - All Lines Pre license Course.

To accept and acknowledge your understanding of this requirement, please sign and date below on the respective lines.

Printed Name Date Signature

Please email this form to affidavits@360training.com or mail it to

360training.com, Attn: Accreditation Department, 13801 Burnet Road, Suite 100, Austin, TX 78727.