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THIS	
  FORM	
  IS	
  NOT	
  PROOF	
  OF	
  CONTINUING	
  EDUCATION	
  CREDIT.	
  TO	
  RECEIVE	
  CONTINUING	
  EDUCATION	
  CREDIT	
  YOU	
  MUST:	
  
1. Fill	
  out	
  this	
  form	
  in	
  its	
  entirety	
  and	
  sign	
  below	
  certifying	
  that	
  you	
  have	
  completed	
  the	
  course	
  and	
  read	
  all	
  applicable	
  material.	
  
2. Please	
  send	
  a	
  faxed	
  copy	
  of	
  the	
  completed	
  form	
  to	
  Affective	
  Learning	
  Labs	
  (Attn:	
  Course	
  Administration)	
  at	
  410-­‐329-­‐1102.	
  
3. Once	
  we	
  have	
  received	
  a	
  copy	
  and	
  confirmed	
  your	
  course	
  completion,	
  a	
  final	
  Certificate	
  of	
  Completion	
  will	
  be	
  sent	
  to	
  you	
  for	
  proof	
  of	
  
continuing	
  education	
  credit.	
  	
  
Student’s	
  Full	
  Legal	
  Name:	
  ____________________________________________________________________	
  
	
  
Student	
  Certificate	
  #:	
  	
   	
   	
   	
   	
   	
   	
   	
   	
   	
   	
   	
  
	
  
Address:	
  	
   	
   	
   	
   	
   	
   	
   	
   	
   	
   	
   	
   	
  
	
  
City,	
  State,	
  Zip	
  	
   	
   	
   	
   	
   	
   	
   	
   	
   	
   	
   	
   	
  
	
  
	
  
I	
  affirm	
  that	
  the	
  work	
  submitted	
  herin	
  is	
  my	
  own	
  work	
  and	
  that	
  no	
  one	
  assisted	
  me	
  with	
  completion	
  of	
  the	
  examination.	
  
	
  
Signature	
  of	
  Student:	
  	
   	
   	
   	
   	
   	
   	
   	
   	
   	
   	
   	
  
	
  
Print	
  Name:	
  	
   	
   	
   	
   	
   	
   	
   	
   	
   	
   	
   	
   	
  
	
  
Date:	
  	
   	
   	
   	
   	
   	
   	
   	
   	
   	
   	
   	
   	
   	
  

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CA Proctor Form (Sample)

  • 1. THIS  FORM  IS  NOT  PROOF  OF  CONTINUING  EDUCATION  CREDIT.  TO  RECEIVE  CONTINUING  EDUCATION  CREDIT  YOU  MUST:   1. Fill  out  this  form  in  its  entirety  and  sign  below  certifying  that  you  have  completed  the  course  and  read  all  applicable  material.   2. Please  send  a  faxed  copy  of  the  completed  form  to  Affective  Learning  Labs  (Attn:  Course  Administration)  at  410-­‐329-­‐1102.   3. Once  we  have  received  a  copy  and  confirmed  your  course  completion,  a  final  Certificate  of  Completion  will  be  sent  to  you  for  proof  of   continuing  education  credit.     Student’s  Full  Legal  Name:  ____________________________________________________________________     Student  Certificate  #:                             Address:                               City,  State,  Zip                                 I  affirm  that  the  work  submitted  herin  is  my  own  work  and  that  no  one  assisted  me  with  completion  of  the  examination.     Signature  of  Student:                             Print  Name:                               Date: