MISSOURI
Monitor Affidavit

I, _____________________________, am a disinterested non related third
                   Name of Monitor
party, disinterested in the passing of the final exams being taken by
__________________________________________ on ________________
Name of Agent                                                                  Date
The monitoring location is at _____________________________________
My phone number is _________________
This student has completed this exam without any assistance from any person
or study material.
Sworn to me this ________, day of __________, 20_____.
___________________________________
Signature
__________________________________
Print or type monitor name
__________________________________
Street Address
__________________________________
City, State, Zip

AFFIDAVIT OF AGENT(TO BE COMPLETED AND SIGNED BY AGENT)

I _______________________________________, affirm that I completed the required
                            Print Name
examination without help or assistance from any outside source in the presence of a
monitor. I completed the following course(s):________________________________
This test(s) was completed on: ____________.

Both fields below are manatory ( without this info., C.E.I.S. cannot process your certificate.)
My License Number is ______________________.
My Social Security Number is ______________________.
My residence address is: _________________________________________________.
Street, City, State, Zip
Date __________________
_____________________________________
Signature of Agent

This signed affidavit must be faxed to Myceisonline at 800-479-8700 immediately after taking your exam for processing. Print This Page